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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601148
Report Date: 08/02/2023
Date Signed: 08/02/2023 12:23:10 PM


Document Has Been Signed on 08/02/2023 12:23 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



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: 105DATE:
08/02/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director, Katherine RaukhmanTIME COMPLETED:
12:40 PM
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On August 2, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced Pre-Licensing visit. LPA met with Executive Director, Katherine Raukhman and explained the purpose of the visit.

LPA toured facility and grounds. Indoor and the outdoor passageways are free of obstruction. No accessible bodies of water or fire safety hazards observed. This is a 4 story facility; Assisted Living on all floors and secure locked Memory Care neighborhood on the first floor. Bedrooms observed during the tour were equipped with sufficient lighting, required furniture, non-skid mats, grab-bars and pull alarm systems. Communal bathrooms observed were clean and free from odor. Water temperatures throughout the facility was measured at 112-113F on each floor. Laundry rooms utilized by residents were located on the 2nd-4th floor. Main laundry room for staff is located on the first floor. Chemicals and toxins were observed to be locked and inaccessible to residents. The first-aid kit is inspected and complete.

Living room and dining room was observed to be comfortable and free from tripping hazards. Comfortable temperature is maintained throughout the facility and lighting is sufficient for comfort. Hallway lights remain on at all hours of the day. Extra linen was observed on the 4th floor. LPA toured the the kitchen and observed it to be clean and sanitary. Facility refrigerator temperatures are within regulatory standards. Dry goods/emergency food supplies are stored on the first floor. LPA observed 2 medication rooms on the first floor; one on the Assisted Living side and one in the Memory Care neighborhood.

A random sampling of resident and staff records is conducted. All required records are maintained. Required posting are posted on the main floor. Facility is overall clean and in good repair based on observations made today. Facility is in compliance with Title 22 regulations. Comp III orientation was given to the Administrator. Immediate Licensure is recommended pending final approval from the Central Applications Bureau.

Report is reviewed with Executive Director and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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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