374604747-2-29-2024-08-AS-DNGN-D2WT68-20240229132644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604747
Report Date: 02/29/2024
Date Signed: 02/29/2024 01:28:27 PM

Document Has Been Signed on 02/29/2024 01:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	IVY PARK AT SABRE SPRINGS		FACILITY NUMBER:	374604747
ADMINISTRATOR:	DAYNES, ROBERT		FACILITY TYPE:	740
ADDRESS:	12515 SPRINGHURST DRIVE		TELEPHONE:	(858) 391-9160
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY:	100	CENSUS: 89	DATE:	02/29/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Applicant's Representative, Robert Daynes		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to the applicant’s representative, Robert Daynes. The facility fire clearance was granted on 01/22/2024 and reflected that the facility was approved for one hundred (100) residents in total, of which eight (8) may be bedridden and all may be non-ambulatory. On the date of LPA's site visit, there were eighty-nine (89) residents in care, of which thirty-seven (37) were non-ambulatory and none were bedridden. The submitted facility sketch was consistent with the current layout of the facility. During today’s visit, LPA, accompanied by the applicant’s representative, toured the interior and exterior of the facility and inspected various rooms. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. The facility’s ambient internal temperature was compliant at 78 degrees F. Hot water temperature at taps accessible to residents were also compliant: 1st Floor Bistro sink was 113.4 F, 1st Floor Lounge sink was 109.4 F, 1st Floor Activity Room sink was 108.3 F, Room #104 sink was 108.4 F, Room #117 sink was 106.3 F; 2nd Floor Therapy Room sink was 107.2 F, Room #203 sink was 109.8 F, Room #223 sink was 107.8 F; 3rd Floor Dining Room sink was 108 F, Room #304 sink was 108.7 F, Room #324 sink was 108.3 F; 4th Floor Dining Room sink was 112.4 F, Room #407 sink was 107.6 F, and Room #423 sink was 111.2 F. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: IVY PARK AT SABRE SPRINGS	FACILITY NUMBER: 374604747
	VISIT DATE: 02/29/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for future resident use. All kitchen appliances were in working order. Appliance temperatures were compliant: Main Kitchen Walk-In Cooler was 37 F, Main Kitchen Salad Cooler was 37 F, 1st Floor Bistro Refrigerator was 29 F, 1st Floor Lounge Refrigerator was 39 F, 1st Floor Activity Room Refrigerator was 38 F, 3rd Floor Dining Room Refrigerators were 38 F and 39 F, and 4th Floor Dining Room Refrigerators were 39 F and 38 F. Main Kitchen Walk-In Freezer was 0 F, Main Kitchen Ice Cream Freezer was 0 F, 1st Floor Lounge Freezer was 0 F, 1st Floor Activity Room Freezer was -8 F, 3rd Floor Dining Room Freezer was 0 F, and 4th Floor Dining Room Freezer was 0 F.

The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of sharp objects, medication, and confidential resident and staff records.

No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant’s representative, no firearms or ammunition are or will be stored at the facility.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Fire extinguishers were serviced within the last twelve months. A complete first aid kit was present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. The applicant passed the pre-licensing inspection.

LPA also provided the Component III Training during today’s visit. Daynes was advised that the facility’s application is pending management final review and approval.

An exit interview was conducted with the applicant’s representative, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC809 (FAS) - (06/04)

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