<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601022
Report Date: 01/30/2024
Date Signed: 01/30/2024 02:58:22 PM


Document Has Been Signed on 01/30/2024 02:58 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: 79DATE:
01/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, Corey MillerTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On January 30, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that was reported on 1/30/2024. LPA met with Administrator, Corey Miller and explained the purpose of the visit. In addition, San Mateo County Fire Inspector, Jose Andrade was present during this visit.

The Licensee reported on 1/30/24 at around 12:30am, the facility had a fire in the kitchen. The fire alarm sounded, and the sprinklers went off in the kitchen. Belmont Fire Department arrived to the facility and the fire was extinguished. No staff or residents were harmed. Kitchen sustained damage to one wall and a several ceiling tiles.

During the visit, LPA toured the facility and grounds. LPA observed the kitchen to be in repair. Damaged ceilings and wall was repaired. Kitchen was observed to be sanitary with all kitchen equipment to be in good repair. According to the administrator, the facility ordered catering services for the day. Residents had pancakes, biscuits, hash browns, eggs, sausage, and fruits for breakfast, sandwiches and potato salad for lunch and will have lasagna, green beans, and pasta for dinner.

During the visit, San Mateo County Fire Inspector and LPA toured all floors. The carpets on the first floor near the kitchen had some water, however during the visit, LPA touched the floors and they were not observed to be wet. According to the Inspector, there were no issues on the Fire Departments end and are okay with the facility resuming kitchen operations. In addition, Inspector Andrade indicated all systems are in good working condition, fire sprinkler that activated in the kitchen was replaced and observed working. Fire extinguishers were currently getting serviced. During the facility tour, Inspector Andrade observed the fire doors throughout the facility and indicated that the door must be self closing and fully latched. Follow up by Fire Inspector will be conducted to ensure compliance.

Facility notified Code Enforcement and Department of Public Health- Environmental Health regarding this incident. Code Enforcement inspector inspected the kitchen on 1/30/24 around 10:30am and indicated that the facility does not require any building permits to fix the damage that was done due to the fire. According to Public Health, this incident is not under their jurisdiction.

No citations were found during the visit. LPA observed kitchen to be in operable condition. Fire Department does not have any issues with resuming kitchen operations. 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: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1