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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202623
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:53:23 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/28/2024 02:53 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:IVY PARK AT PALO ALTOFACILITY NUMBER:
435202623
ADMINISTRATOR:FRANGIEH, CAROLINEFACILITY TYPE:
740
ADDRESS:2701 EL CAMINO REALTELEPHONE:
(703) 273-7500
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:97CENSUS: 68DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Chris SchusterTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year annual visit and met with Chris Shuster.

During visit, LPA Marrufo toured the facility inside and out. LPA toured 4 hallway bathrooms and observed each bathroom to have working lights and available soap and paper towels. The water temperatures in the bathroom sinks ranged from 109 F - 114 F. LPA toured the facility kitchen area and observed the kitchen to have a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured the outside areas and observed the exits were clear of obstructions.

LPA reviewed the resident records and Centrally Stored Medication and Destruction Records (CSMDR) for 5 residents. All 5 reviewed CSMDRs were found to be complete. Resident R1 and R2's resident records were missing Safeguard for Property and Valuables forms. LPA reviewed the staff records for five staff. Staff S1 was missing a current first aid certification.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D page for more information.

This report was reviewed with Chris Shuster and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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Document Has Been Signed on 08/28/2024 02:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: IVY PARK AT PALO ALTO
FACILITY NUMBER: 435202623

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/04/2024
Section Cited
CCR
87411(c)(1)

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87411(c)(1) Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
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Licensee agrees to submit a copy of Staff S1’s current first aid certification to CCL by POC date. Licensee also agrees to audit all staff records to ensure that all staff who provide care have current first aid certifications.
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(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement was not met as evidenced by: Licensee did not ensure that 1 out of 5 reviewed staff records included a current first aid certification, which poses a potential safety risk to residents in care.
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Type B
09/04/2024
Section Cited
CCR87506(b)(16)

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87506 (b) Each resident’s record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement was not met as evidenced by: Licensee did
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Licensee agrees to submit copies of resident R1 and R2’s Safeguard for Property and Valuables forms to CCL by POC date.
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not ensure that 2 out of 5 reviewed resident records included Safeguard for Property and Valuables forms, which poses a potential personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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