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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804017
Report Date: 06/22/2023
Date Signed: 06/22/2023 03:34:51 PM


Document Has Been Signed on 06/22/2023 03:34 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: 101DATE:
06/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator, Stephanie LimbergTIME COMPLETED:
03:45 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, an incident report was forwarded to Community Care Licensing Regional Office on June 10, 2023. Incident Report summarizes that a resident had a fall, injury and subsequent hospital visit. LPA learned that the resident is doing good at this time and was prescribed some medication for the pain throughout the night. Administrator shared that the Care Plan will be updated with the family. LPA attempted to interview the Resident in care and was unsuccessful. During this Case Management-Incident Inspection, LPA reviewed the following document:

-Care Plan

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: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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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