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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804017
Report Date: 08/30/2023
Date Signed: 10/03/2023 11:45:58 AM


Document Has Been Signed on 10/03/2023 11:45 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/03/2023 11:17 AM

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

NARRATIVE
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"AMENDED" This is an amended version of the original report created on August 30, 2023 which a Type A Deficiency as issued. Facility Appealed and CCL determined that a Type B deficiency is warranted. LPA is Amending this report from a Type A deficiency to a Type B deficiency. (See LIC 809D for the change)

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 the receptionist, Sony Pastor. Administrator arrived 20 minutes later.

During this Case Management-Incident inspection, LPA interviewed the Administrator and attempted to interview two residents in care, but were unsuccessful. LPA reviewed training documents regarding Staff Member #1 (S1). LPA learned that during the incident in question, emails depicting inappropriate photos of two residents in placement were sent to the Administrator via a cellular device and by email (See LIC 809D). LPA learned that the staff member was written up for the alleged photography. LPA educated the Administrator regarding that photography of residents are not to be taken on personal cell phones.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview was conducted with the Administrator and appeal rights were emailed.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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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Document Has Been Signed on 10/03/2023 11:46 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/03/2023 11:22 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ROSA
FACILITY NUMBER: 496804017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/31/2023
Section Cited
HSC
1569.269(a)(3)

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Health and Safety Code 1569.269
Enumerated rights; severability:

(a) Residents of residential care facilities for the elderly shall have all of the following rights:
(3) To confidential treatment of their records and personal information and to approve their release, except as authorized by law.
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Plan of Correction was already completed via in-service training conducted on July 2023. LPA requested the Administrator to submit an LIC 9098-Self Certification and a summary on how future compliance will be met.
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This requirement was not met as evidenced by:

Based on an interview with the Administrator, LPA learned that during the incident in question, emails depicting inappropriate photos of two residents in placement were sent to the Administrator via a cellular device and by email which is an immediate health, safety and personal rights risk to the residents in care.
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Plan of Correction due on August 31, 2023.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2