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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604768
Report Date: 09/17/2024
Date Signed: 09/17/2024 05:26:55 PM


Document Has Been Signed on 09/17/2024 05:26 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
SAN DIEGO RO, 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:
09/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:18 PM
MET WITH:Executive Director Megan FranzTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA), Juliana Barfield conducted a Case Management - Incident visit. LPA met with Executive Director, Megan Franz and discussed the purpose of the visit.

Community Care Licensing received a self reported Incident Report involving Resident #1 (R1). The Incident Report stated that R1 left the facility unassisted through delayed egress doors that sounded an alarm on 9/13/24 at 10:00am. R1 was found by staff unharmed at a nearby store. Resident returned to facility with staff at 10:10am.

Today, LPA requested records relevant to the Incident Report. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Megan Franz whose signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Juliana BarfieldTELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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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