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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 10/07/2025
Date Signed: 10/07/2025 10:54:22 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2025 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20250728162028
FACILITY NAME:IVY PARK AT ROCKVILLEFACILITY NUMBER:
486803653
ADMINISTRATOR:TEDRA GODFREYFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 356-2229
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: 127DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrartor, Tedra GodfreyTIME COMPLETED:
11:10 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of adequate staffing resulted in resident care needs not being met.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to continue a complaint Investigation and delivered the findings regarding the above allegation and met with Administrator, Tedra Godfrey.
During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Lack of adequate staffing resulted in resident care needs not being met.”
The complaint alleged that Resident 1 (R1) sustained multiple unwitnessed falls, bruises, and a possible heel wound while residing at the facility, and that inadequate staffing may have contributed to unmet care needs.
LPA interviewed the Administrator and caregiver staff, who confirmed R1 had several falls, and that Special Incident Reports (SIRs) were submitted. R1 was described as independently mobile and on blood thinners, which may have contributed to bruising. A full body assessment was completed upon admission, and staff denied observing any heel wounds or unmet care needs during R1’s stay.
Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20250728162028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: IVY PARK AT ROCKVILLE
FACILITY NUMBER: 486803653
VISIT DATE: 10/07/2025
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
26
27
28
29
30
31
32
Continued from LIC9099...

There was no evidence that inadequate staffing contributed to R1’s condition or that resident care needs were not met.

Based record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2