486803653-5-8-2025-21-AS-VBEI-DGMVSB-20250513164115

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 05/08/2025
Date Signed: 05/08/2025 01:24:45 PM

Unfounded

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
05/05/2025 and conducted by Evaluator Ali Deniz

COMPLAINT CONTROL NUMBER: 21-AS-20250505101506

FACILITY NAME:	IVY PARK AT ROCKVILLE		FACILITY NUMBER:	486803653
ADMINISTRATOR:	KRYSTAL JENKINS		FACILITY TYPE:	740
ADDRESS:	4625 MANGELS BLVD		TELEPHONE:	(707) 862-2222
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	199	CENSUS:	DATE:	05/08/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator, Tedra Godfrey		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Staff are not posting required documents in the facility for the residents

INVESTIGATION FINDINGS:

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At approximately 1:00PM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegation and met with Administrator, Tedra Godfrey.

During the course of the investigation, the Department made observations. There is an allegation of "Staff are not posting required documents in the facility for the residents.” Complainant alleged that the facility was not displaying required posters to inform residents and staff about important rights and regulations. These included posters outlining resident rights, complaint procedures, and information about the Long-Term Care Ombudsman."

Continued on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Ali Deniz	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250505101506

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: 05/08/2025

NARRATIVE

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Continued from LIC9099

LPAs conducted a walkthrough of the facility and found that the required postings were located in the resident mail room. Per conversation with Administrator, additional posters are also located in the staff room.

Based on observations made, this allegation is Unfounded. A finding that the complaint is UNFOUNDED means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Ali Deniz	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC9099 (FAS) - (06/04)

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