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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804017
Report Date: 05/08/2023
Date Signed: 05/08/2023 02:15:06 PM


Document Has Been Signed on 05/08/2023 02:15 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:IVY PARK AT SANTA ROSAFACILITY NUMBER:
496804017
ADMINISTRATOR:STEPHANIE LIMBERGFACILITY TYPE:
740
ADDRESS:4225 WAYVERN DRIVETELEPHONE:
(707) 538-2590
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:114CENSUS: 100DATE:
05/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator, Stephanie LimbergTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Ivy Park At Santa Rosa for the purpose of conducting a Case Management-Incident Inspection. LPA was greeted at the door by Administrator, Stephanie Limberg, and was granted access into the facility.

During the Case Management-Incident inspection, LPA requested the following document for an incident that was submitted to CCL on April 22, 2023:

-LIC 602

During the Case Management-Incident inspection, LPA reviewed the LIC 602 at the facility and found that the resident was NOT on a Special Diet. Furthermore, facility followed all proper procedures as it relates to this incident report.

Also on this date and time, LPA followed up with another incident report that was submitted on May 5, 2023 regarding a resident to resident altercation at the facility. LPA interviewed the Administrator and the two residents. LPA learned that both residents have no recollection of what occurred and have assimilated back into the community. Furthermore, LPA learned that the Care Plans will be updated for both residents in care.

No deficiencies were observed or cited during today's Case Management-Incident inspection. Exit interview was conducted and a copy of this report was given to the facility Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
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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