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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601148
Report Date: 08/21/2024
Date Signed: 08/21/2024 03:22:15 PM


Document Has Been Signed on 08/21/2024 03:22 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 AT GOLDEN GATE, THEFACILITY NUMBER:
385601148
ADMINISTRATOR:RAUKHMAN, KATHERINEFACILITY TYPE:
740
ADDRESS:1601 19TH AVENUETELEPHONE:
(415) 664-6264
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:168CENSUS: 127DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Katherine Raukhman, Executive DirectorTIME COMPLETED:
03:30 PM
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On 8/21/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Executive Director, Katherine Raukhman. The facility currently provides care for 127 residents, 6 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, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located on each resident floor and kitchen were found to be last charged on 11/8/2023. Carbon monoxide detectors were located at each hallway tested and functioning. Smoke detectors and fire safety systems are interconnected. Fire Safety Inspection was completed on 8/16/2024 indicating all fire safety devices and systems to be in order. Water at faucets accessible to residents measured between 105.3 and 114.4 degrees F which is within regulation.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished twice per week and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked closets throughout each floor, 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 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 found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis. Residents were observed to have a positive and personable relationship with staff and Executive Director. There are multiple outdoor patios for resident use, all equipped with appropriate shading Continued onto LIC809-C
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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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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 AT GOLDEN GATE, THE
FACILITY NUMBER: 385601148
VISIT DATE: 08/21/2024
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LPA conducted a sample file review for 10 residents and found all items to be in order. Upon a spot check of five (5) staff files, LPA found that caregiver staff have current 1st aid and CPR and annual training completed. Lastly, A spot check of medications in both assisted living and memory care was conducted and found that all medication counts and records are in order.

Katherine Raukhman's Administrator Certificate 7007732740 is currently active through 12/26/2024.

LPA requested the following documents be sent to CCL by COB 9/4/2024:

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

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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