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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601022
Report Date: 12/27/2023
Date Signed: 12/27/2023 01:22:36 PM


Document Has Been Signed on 12/27/2023 01:22 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
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: 78DATE:
12/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Corey MillerTIME COMPLETED:
01:35 PM
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On December 27, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection visit. LPA met with Administrator, Corey Miller and explained the purpose of the visit.

LPA toured the facility and grounds, no accessible bodies of water or fire safety hazards observed. This is a three floor facility with assisted living (AL) residents on all three floors and memory care residents on part of the third floor. LPA observed an two elevators on each floor. Lighting is sufficient for comfort and a comfortable temperature of 72 degrees F is maintained. Communal bathrooms were observed to be clean and odor-free.

Medications were observed locked in a centralized storage area on the second floor. Toxins, chemicals and sharps were observed to be locked an inaccessible to residents. Kitchen was observed to be clean. LPA observed 2-day perishable and 7-day non-perishables present. Nine resident rooms were observed to be equipped with all required furniture. Water temperature throughout the facility measured between 109-111 degrees F.

Delayed egress on third floor memory care unit was tested and observed to be working. LPA checked all fire extinguishers, which were inspected on 11/2023. First aid kit was observed to be present. Carbon monoxide detectors were observed to be in working condition.

LPA reviewed facilities emergency/ disaster plan. The last disaster drill was conducted on 10/2023. LPA reviewed 5 resident files and 5 staff files. All records reviewed were up to date and current.

No deficiencies are cited. 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: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
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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