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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604768
Report Date: 08/14/2024
Date Signed: 08/14/2024 05:00:09 PM


Document Has Been Signed on 08/14/2024 05:00 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:IVY PARK AT LA JOLLAFACILITY NUMBER:
374604768
ADMINISTRATOR:FRANZ, MEGANFACILITY TYPE:
740
ADDRESS:810 TURQUOISE STREETTELEPHONE:
(858) 488-4300
CITY:SAN DIEGOSTATE: CAZIP CODE:
92109
CAPACITY:76CENSUS: 53DATE:
08/14/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Megan Franz, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA), Daniel Pena, conducted an announced Pre-licensing and Component III inspection. LPA was greeted in the lobby by staff and after introducing and identifying himself was allowed into the facility. LPA was greeted by Administrator Megan Franz to whom LPA stated the purpose of the visit. The facility is in current operation with census of fifty-three (53) residents on the day of the inspection.

The application for this license requests a change of ownership. LPA verified that the LIC 309 Administrative Organization form was modified to reflect the change. Certificate of Liability Insurance was reviewed and is valid through 05/01/2025 and includes the required coverage limits. A fire clearance was granted on 5/6/2024. The facility is approved to serve seventy-two (72) non-ambulatory and four (4) bedridden residents who may occupy any apartment on the first and second floor. Administrator Franz’ certification is valid through March 2025.

LPA, accompanied by Administrator Franz, conducted a tour of the facility which included communal dining, activity and group meeting rooms as well as a sample of resident rooms. Passageways are free from obstructions. There is no pool or other body of water on the property. According to Administrator Franz, no firearms or dangerous weapons are stored on the premises. Residents' bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid materials. Hot water temperatures were recorded at a sampling of faucets for resident's use and measured within 105-120, degrees Fahrenheit. LPA observed carbon monoxide and smoke detector devices which were present and operable. According to facility records, a fire drill was conducted on 7/8/2024.

Medications and administration records were observed and stored in a secured location. A sample of resident and staff records were reviewed. Facility staff records contain health screenings, background checks, and First Aid certifications. Resident records include admission agreements, medical assessments, and physician reports as well as a needs and services plans.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: IVY PARK AT LA JOLLA
FACILITY NUMBER: 374604768
VISIT DATE: 08/14/2024
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CONTINUED FROM LIC812


At this time, the facility is operating within compliance with California Code of Regulations, Title 22. Administrator Franz was advised that the application is pending final review and management approval. Component III was also completed. A copy of this report was discussed and provided to Administrator Franz, along with the Licensee/Appeal Rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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