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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804017
Report Date: 10/03/2023
Date Signed: 10/03/2023 11:50:48 AM


Document Has Been Signed on 10/03/2023 11:50 AM - 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:
10/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Stephanie LimbergTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of conducting a Case Management-Incident inspection to discuss three incidents that were reported by the facility to CCL, and to also Amend a Report that was issued on August 30, 2023 in which a Type A deficiency was issued. Facility appealed, and CCL determined that a Type B deficiency is warranted instead. LPA changed the deficiency from a Type A to a Type B deficiency (See LIC 809-Case Management-Incident inspection dated for August 30, 2023)

CCL received an incident report on September 20, 2023 indicating a residents jewelry went missing. Administrator contacted the appropriate parties which includes the Responsible Party via email. LPA requested the following documents:
-LIC 602

CCL received an incident report on September 25, 2023. Resident had a left hip fracture due to falling off a chair that was placed in his apartment. Administrator contacted the appropriate parties which includes the Responsible Party. Resident was not a fall risk and there were no prior fall incidents regarding this resident. Facility will reassess resident and determine what additional needs (if any) are needed for this resident.

CCL received an incident report indicating a fall that occurred on September 27, 2023 indicating that there was one rodent (rat) that was an apartment. Administrator cleaned, fumigated and eradicated the room. In addition, facility hired a pest control company to ensure that there was no rodent infestation. LPA requested the following document:
-Eco-Lap pest control receipt

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 Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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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