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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804017
Report Date: 02/02/2024
Date Signed: 02/02/2024 04:54:51 PM


Document Has Been Signed on 02/02/2024 04:54 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: 101DATE:
02/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Stephanie Limberg, AdministratorTIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by Stephanie Limberg, Administrator. Facility currently has 101 residents in care..

On 1/31/2024 CCL received from facility a SOC341 report of abuse, type of abuse reported is sexual assault. Suspected abuser is unknown. At approximately 1:45pm on 1/31/2024, resident (R1) reported to Admin they were sexually assaulted. R1 reported that the suspect entered their apartment, put a hand over their mouth, held them down and assaulted them. Admin notified Santa Rosa Police Dept (event #SR24-1243) immediately upon reporting of assault.

R1 transported to hospital for evaluation at approximately 4:35pm on 1/30/2024. Description of suspect was given to Admin and authorities. Per LPA interview with Admin, no one on staff matches that description. Admin also notified R1's responsible party at approximately 2:01pm and 4:35pm. R1 discharged from hospital on 2/1/2024 and is currently residing with responsible party at a hotel. No definitive return date to facility has been determined or communicated, as of today.

LPA requested hospital discharge information, updated LIC602, updated Care Plan, and police report. Per Admin, hospital refused to provide them with discharge information. Therefore, an updated care plan is not available. Per Admin, police report not available yet. LPA to request police report. Updated LIC602 will be provided to CCL once by Admin.

LPA obtained documents and made observations. LPA will follow up with assigned detective and will return to facility for follow-up.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
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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