435202847-4-21-2022-26-AS-CDOS-CDQ2A4-20220421171255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202847
Report Date: 04/21/2022
Date Signed: 04/21/2022 05:13:04 PM

Document Has Been Signed on 04/21/2022 05:13 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	IVY PARK AT SAN JOSE		FACILITY NUMBER:	435202847
ADMINISTRATOR:	POST, SARA		FACILITY TYPE:	740
ADDRESS:	4855 SAN FELIPE ROAD		TELEPHONE:	(408) 223-1312
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	140	CENSUS: 97	DATE:	04/21/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Sara Post		TIME COMPLETED:	05:20 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	Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a pre-licensing visit. LPA met with Sara Post, Administrator. There is currently residents living at the facility. The facility has three floors to consist of assisted living and one floor memory care. The facility has an approved fire clearance for 140 non-ambulatory and 21 bedridden residents. LPA toured the facility inside including the apartments, bathrooms, kitchen, and common areas. Resident apartments were equipped with proper furniture and lighting. Resident apartment temperature was maintained between 74 to 77 degrees Fahrenheit. Residents are responsible in providing personal bedding and linens upon admission. Facility does not provide bedding and linens. Bathrooms are equipped with grab bars, nonskid floors, hygiene supplies, and toiletry. Facility is equipped with cups, plates, utensils, and cooking supplies. Hot water temperature was measured between 111.3 to 113.3 degrees Fahrenheit. The facility has designated medication rooms with locked medication cabinets. LPA reviewed centrally stored medication records with residents medications. LPA observed first aid kit. LPA observed locked medications, sharp objects, and cleaning supplies. Continue on LIC-809C

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 04/21/2022

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LPA observed 2 days worth of perishables and 7 days worth of nonperishable. Refrigerator temperature was maintained at 31 degrees Fahrenheit. Freezer temperature was maintained at 1 degree Fahrenheit.

Facility is equipped with smoke detectors, carbon monoxide detector, and fire extinguisher. Hallway and passageways were observed free of obstruction.

The following posters observed: personal rights, if you see something say something, ombudsmen, and resident right to counsel posted.

LPA reviewed 6 resident files and 5 staff files. Facility staff are fingerprint cleared. Resident files consist of Physician's Report, TB information, Emergency Information, Centrally Stored Medication Records, and Personal Rights. Staff files all consist of Personal Record, Health Screening with TB Information, and Criminal Record Statement.

Component III is being waived.

The Department is recommending licensure pending the plan of correction for the deficiency issued during today's pre-licensing visit. See LIC809 for 04/21/2022 under facility #435202621.

LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Sara Post, Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

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