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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804017
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:45:24 PM


Document Has Been Signed on 10/20/2023 03:45 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
SANTA ROSA RO, 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: 103DATE:
10/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Executive Director Stephanie LimbergTIME COMPLETED:
03:55 PM
NARRATIVE
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At approximately 3:00pm LPAs Christi Coppo and Victoria Bertozzi arrived unannounced to conduct a case management regarding Incent Report received on 10/06/2023.

Per facility’s Incident Report: On 10/05/2023 a visitor came to visit resident (R1), upon looking for R1 it was discovered that R1 was not in the facility. The last time R1 was accounted for was at approximately 2:15pm while engaging in activities in the community living room. R1 has a diagnosis of dementia and resides in Memory Care. Staff located R1 at approximately 5:15pm at the Santa Rosa Memorial Hospital Emergency room. R1 was evaluated at the hospital’s ER and was found to have no injuries, no new diagnoses, or new medication orders. R1 was released from hospital’s ER at approximately 6:07pm.

LPAs reviewed R1’s assessment and clarified resident has known exit seeking behavior. Per LPAs’ conversation with Administrator, facility immediately conducted additional training with staff. Also, Administrator has increased staff monitoring of R1.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code.


This report was reviewed with Administrator and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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 10/20/2023 03:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 SANTA ROSA
FACILITY NUMBER: 496804017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
CCR
87705(c)(4)

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87705 Care of Persons with Dementia
(c) (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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Facility immediately conducted additonal training with staff. Also, Adminstrator has increased staff monitoring of R1 and increased activities. Deficiency is cleared.
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This requirement is not met as evidenced by: based on document review, Licensee did not meet requirement by R1 eloping a locked memory care unit. This poses a potential Health, Safety or Personal rights risk to residents.
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
LIC809 (FAS) - (06/04)
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