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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202621
Report Date: 03/24/2022
Date Signed: 03/25/2022 08:25:46 AM


Document Has Been Signed on 03/25/2022 08:25 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:IVY PARK AT SAN JOSEFACILITY NUMBER:
435202621
ADMINISTRATOR:SARA POSTFACILITY TYPE:
740
ADDRESS:4855 SAN FELIPE RDTELEPHONE:
(408) 223-1312
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:140CENSUS: 99DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Sara PostTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Annual Inspection visit today, and met with administrator(ADM) Sara Post.

Upon Arrival, the facility front desk staff took LPA's body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. LPA observed many hand sanitizers in the facility. LPA toured the dinning noon, common area, activity room in memory care unit and assisted living unit. Trash cans were observed with covers. Kitchen and laundry room were inspected. Public restrooms were inspected. LPA toured the resident rooms in Assistant Living Unit, and Memory Care Unit. The beds in shared rooms were observed 6 feet apart. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication room, and cleaning product room were observed locked. Medication carts were observed locked. Room temperature was at 73 degree F, and hot water temperature was at 108 degree F.

Fire extinguisher was serviced on 01/22/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by staff, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. The facility does not have swimming pool.

ADM stated all the staff and residents are fully vaccinated. ADM stated 99% staff and 95% residents are done with booster. No deficiency or citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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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