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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601148
Report Date: 05/23/2024
Date Signed: 05/23/2024 08:57:44 AM


Document Has Been Signed on 05/23/2024 08:57 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
SAN BRUNO RO, 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: 110DATE:
05/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Katherine Raukhman, Executive Director TIME COMPLETED:
09:15 AM
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On May 23, 2024, at 8:45 AM, Licensing Program Analyst (LPA) John Calandra conducted an unannounced visit. LPA Calandra met with Executive Director, Katherine Raukhman and explained the purpose of today’s visit.

LPA Calandra delivered an immediate exclusion letter to exclude a private companion who worked in the facility before. The private companion is not on shift today and the Executive Director was advised that they are not allowed to work in the facility.

The letter was given to and reviewed by the Executive Director, Katherine Raukhman. This report is reviewed and discussed, and a copy is provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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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