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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601148
Report Date: 05/05/2023
Date Signed: 07/10/2023 11:09:49 AM


Document Has Been Signed on 07/10/2023 11:09 AM - 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:IVY AT GOLDEN GATE, THEFACILITY NUMBER:
385601148
ADMINISTRATOR:RAUKHMAN, KATHERINEFACILITY TYPE:
740
ADDRESS:1601 19TH AVENUETELEPHONE:
(415) 664-6254
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:168CENSUS: DATE:
05/05/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:KATHERINE RAUKHMANTIME COMPLETED:
11:30 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity:168
Census (if any clients in care):
COMP II Participants: KATHERINE RAUKHMAN, ADMINISTRATOR
Interview Method: Telephone interview

On 5/5/23, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Stefania FontenoTELEPHONE: (916) 657-2335
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
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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