435202847-5-7-2024-26-AS-MPAA-D52KRS-20240507080821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202847
Report Date: 04/24/2024
Date Signed: 05/07/2024 08:08:27 AM

Document Has Been Signed on 05/07/2024 08:08 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	IVY PARK AT SAN JOSE		FACILITY NUMBER:	435202847
ADMINISTRATOR:	NEVAREZ, KARINA		FACILITY TYPE:	740
ADDRESS:	4855 SAN FELIPE ROAD		TELEPHONE:	(408) 223-1312
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	140	CENSUS: 124	DATE:	04/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Karina Nevarez - Executive Director		TIME COMPLETED:	05:15 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	Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required annual inspection and met with facility Administrator (ADM) Karina Nevarez. The facility's censis is 124 residents and 77 staff. LPA toured the interior of the facility, including entryway, common room, dining room, kitchen, laundry room, resident bedrooms, bathrooms, medicine room, and activities room. LPA toured the exterior of the facility and observed all walkways are free from obstruction. LPA observed the following there were no prohibited items observed in the resident rooms. All emergency exits are clear from obstruction. Facility has activities scheduled posted for the whole month. LPA observed residents participating during activity time. LPA observed staff assisting residents in the dining room and are present on the hallways to give assistance to residents. LPA tested the facility water temperature. Water temperature measured between 112 to 116 degree Fahrenheit. LPA observed sufficient supply of food, 2 days of perishable food and 7 days for non-perishable food. Fire extinguisher was last inspected on 05/15/2023. All toxins are kept in a locked room. Knives are locked and is not accessible to residents. Carbon monoxide alarms are placed in the hallways and each apartment unit. The room temperature is at 70 degrees F. Skid matts and grab bars in the bathrooms. continued to LIC 809C page 2

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

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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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 SAN JOSE	FACILITY NUMBER: 435202847
	VISIT DATE: 04/24/2024

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LPA reviewed the facility record and observed that the fire alarm is maintained and serviced by Fire Safety Service Inc. and the company provides simulation training to facility staff for different shifts. The fire alarms system for the entire building was tested on 3/1/2024 and 3/18/2024 and found to be in good working conditions.

LPA reviewed resident's record and observed no deficiency, record is complete and updated. LPA reviewed the facility staff record and observed that record is up to date including staff training. LPA review the centrally stored medication and destruction record (CSMDR) and found the record to have sufficient information. LPA conducted advisory assistance for future record keeping regarding dates started and expiration dates on the CSMDR.

No deficiency was cited during today's visit annual required visit. An exit interview was conducted with Executive Director Karina Nevarez and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC809 (FAS) - (06/04)

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