496804017-1-4-2024-21-AS-CCOO-CZ6VUQ-20240104154506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804017
Report Date: 01/04/2024
Date Signed: 01/04/2024 03:45:15 PM

Document Has Been Signed on 01/04/2024 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 ROSA		FACILITY NUMBER:	496804017
ADMINISTRATOR:	STEPHANIE LIMBERG		FACILITY TYPE:	740
ADDRESS:	4225 WAYVERN DRIVE		TELEPHONE:	(707) 538-2590
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	114	CENSUS: 100	DATE:	01/04/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Stephanie Limberg, Admin		TIME COMPLETED:	04:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

At approximately 12:50pm LPA Christi Coppo arrived unannounced to conduct a case management regarding Incident Report (IR) received on 12/15/2023. LPA was greeted by Stephanie LImberg, Administrator.

On 12/15/2023 CCL received SOC341 reporting abuse of resident (R1) in the form of theft of a cellphone. Admin cross reported incident to ombudsman and a police report was filed. Admin contacted Santa Rosa Police Department via telephone number 707.528.5222 at approximately 1:00pm on 12/14/2023 and was advised to submit an online report. Admin filed online report (report number SR230015983) at approximately 3:45pm on 12/14/2023.

Per LPA interview with Admin, on 12/14/2023 Admin was notified by resident's family member (I1) that cellphone belonging to R1 could not be located. I1 reported to Admin that they first noticed R1's cellphone missing about 2-3 months ago but did not say anything. I1 reported to Admin that R1's phone was not actually utilized as a typical phone in that R1 did not use it to make phone calls. I1 indicated the phone was utilized as an alarm that would serve as a reminder for R1 to eat meals.

Per Admin, on some day in September, R1's cellphone was accidentally washed by the staff. Upon realizing the phone had been put through the wash cycle, staff put the phone in rice to dry out. After the phone had been sufficiently dried, staff returned the cellphone to R1. Staff witnessed R1 place cellphone on its charger. Subsequently, staff notified I1 of R1's phone being washed, dried, and given back to R1. This is the last time the phone was seen; R1's apartment is its last known location.

I1 reported to Admin that despite the phone being missing I1 was still paying for the cellphone service. I1 attempted to reactivate phone in hopes of finding its location. Upon speaking with the cellphone carrier's representative, I1 was informed that someone attempted to put in a new SIM card, so the phone is now locked out. Upon learning this, I1 notified Admin that R1's phone was stolen. However, I1 could not provide date of attempted SIM card replacement nor the date on which I1 called the cellphone carrier.

Continued on 809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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
	VISIT DATE: 01/04/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 809...

Per Admin, R1's apartment was searched by Admin, facility staff and I1, all parties unable to locate the cellphone. Cellphone carrier unable to locate the cellphone remotely. Approximate value of cellphone is $400.

Upon arrival of LPA today, Admin provided LPA copies of: Santa Rosa Police Department Summary Incident Report, R1's Care Plan, R1's LIC602, and R1's Client/Resident Personal Property and Valuables list completed at time of R1's admission to the facility. LPA reviewed all provided documents.

LPA observed R1's care plan to indicate that R1 requires meal-time reminders, staff are therefore tasked to remind resident to attend meals. Per care plan, R1 can ambulate to dining room without assistance and maintains ability to attend meals in the dining room; staff to help R1 to maintain independence in dining.

LPA reviewed R1's Client/Resident Personal Property and Valuables list. List was blank, no valuables listed. List was signed by R1's POA and dated 8/9/2021.

LPA interview with Admin and LPA review of police report, R1's Care Plan, R1's LIC602, and Inventory of items Admin has conducted an investigation, cross-reported incident to appropriate parties, and filed a police report upon being notified of missing cellphone.

No deficiencies cited during this investigation.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2