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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600429
Report Date: 04/23/2024
Date Signed: 04/23/2024 02:27:57 PM


Document Has Been Signed on 04/23/2024 02:27 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:ELLA FRICKFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 120DATE:
04/23/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Alan Fox, Regional Operations SpecialistTIME COMPLETED:
02:30 PM
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On April 23, 2024 at 9:30 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct an unannounced Case Management-Health and Safety check in regards to an incident report received by the department on April 22, 2024 regarding the death of a resident. LPA Calandra was greeted by Alan Fox, Regional Operations Specialist and explained the purpose of the visit.

LPA Calandra requested and received the following documents:

-Resident's LIC 602-Physician's report
-Annual Needs and Service Plan or Care Plan
-Admissions Agreement
- Progress notes
- Resident's Medication Records
- Doctor's orders
- Resident Record
- Hospice Notes

No deficiencies were cited during today's visit.

This report was reviewed with Alan Fox, Regional Operations Specialist and a copy of the report left at the facility.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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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