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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601022
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:56:00 PM


Document Has Been Signed on 08/09/2023 03:56 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 PARK AT BELMONTFACILITY NUMBER:
415601022
ADMINISTRATOR:MILLER, COREYFACILITY TYPE:
740
ADDRESS:1010 ALAMEDA DE LAS PULGASTELEPHONE:
(650) 508-0400
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:117CENSUS: 76DATE:
08/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, Corey Miller TIME COMPLETED:
04:10 PM
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On August 9, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that was reported on August 7, 2023. LPA met with Administrator, Corey Miller and explained the purpose of the visit.

The Licensee reported on August 3, 2023, Resident 1 (R1) and Resident 2 (R2) were found in the hallway bickering with each other and their arms locked by a staff member (S1). Scratches were noted on both residents.

During the visit, LPA discussed incident with administrator and reviewed resident files. Based on file reviewed, R1 and R2 both have a diagnosis of dementia. LPA observed R1's and R2's care plan.

Based on R1's care plan, R1 does have a history of experiencing combative episodes. In addition, R1's care plan indicates that physician adjusted his/her medication and behavior mapping is being conducted. Based on R2's care plan, R2 does not have a history of aggressive or combative behavior.

The administrator indicated R1 and R2 have not shown any combative or aggressive behaviors since the incident.

No citations are issued during the visit. Report is reviewed with administrator 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: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
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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