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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600429
Report Date: 02/25/2025
Date Signed: 02/25/2025 03:49:36 PM

Document Has Been Signed on 02/25/2025 03:49 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:IVY PARK AT CATHEDRAL HILLFACILITY NUMBER:
385600429
ADMINISTRATOR/
DIRECTOR:
ELLA FRICKFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY: 210CENSUS: 164DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Alan Fox, Regional Operations SpecialistTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 2/25/2025, Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Regional Operations Specialist, Alan Fox. The facility currently provides care for 164 residents, 10 of which are receiving hospice services along with a designated memory care unit.

LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, memory care unit and resident common spaces were inspected. Fire Extinguishers located throughout the inspected portions of the building were found to be charged. Smoke and carbon monoxide detectors and fire safety systems are interconnected.

Cleaning supplies and other toxins are safely stored in locked closets throughout the facility, and housekeeping/maintenance rooms all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items.

Residents in the memory care unit that were awake during the inspection were observed interacting with staff, fellow residents and visitors in the common areas, or in their bedrooms resting. The facility encourages regular family visits and utilizes a wide variety of activities with LPA observing staff engaging continuously with residents, offering activities based on individualized preferences and abilities. LPA observed group karaoke and movies presented to residents along with a variety of activity supplies available. LPA found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis. Residents were found to have a positive and personable relationship with staff.
Continued onto LIC809-C
Andrea Medlin
Dominic Tobola
DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: IVY PARK AT CATHEDRAL HILL
FACILITY NUMBER: 385600429
VISIT DATE: 02/25/2025
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LPA conducted a sample file review for 10 residents and found all items to be on file. LPA's found that residents Needs & Service Plans and Medical Assessments were up to date. Upon a spot check of 10 staff files, LPA found that caregiver staff have current first aid and annual training, health screenings and TB results on file. Lastly, a spot check of medications was conducted and found that all medication counts and records are in order.

LPA will be conducting an annual continuation to further inspect remaining resident living quarters, kitchen and food supply and facility transportation.

Executive Director, Fili Igafo's Administrator Certificate 7003332740 is currently pending for renewal but has been received by the department with application received 11/18/2024.

LPA requested the following documents be sent to CCL by COB 3/11/2025:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
Liability Insurance

No deficiencies cited during the visit.
SUPERVISOR'S NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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