<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202847
Report Date: 08/27/2024
Date Signed: 08/27/2024 04:24:39 PM


Document Has Been Signed on 08/27/2024 04:24 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 SAN JOSEFACILITY NUMBER:
435202847
ADMINISTRATOR:NEVAREZ, KARINAFACILITY TYPE:
740
ADDRESS:4855 SAN FELIPE ROADTELEPHONE:
(408) 223-1312
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:140CENSUS: 116DATE:
08/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Karina Nevarez - Executive Director/AdministratorTIME COMPLETED:
04:30 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
On 8/27/2024 at approximately 1:58 p.m. , Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management visit regarding an incident report that was received by the department on 8/23/2024 involving a resident. LPA met with Executive Director/Administrator (ED/ADM) Karina Nevarez and LPA stated the purpose of the visit.

LPA conducted a file review and requested copies of the resident's file including but not limited to admission agreement, medication list, physician's report, appraisal needs and services plan, incident report and background history.

No deficiency cited during today's visit. Due to insufficient information this case management will remain open until further investigation.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1