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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804017
Report Date: 06/24/2022
Date Signed: 06/24/2022 04:12:49 PM


Document Has Been Signed on 06/24/2022 04:12 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:IVY PARK AT SANTA ROSAFACILITY NUMBER:
496804017
ADMINISTRATOR:SAFOORA AHMEDFACILITY TYPE:
740
ADDRESS:4225 WAYVERN DRIVETELEPHONE:
(707) 538-2590
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:114CENSUS: 73DATE:
06/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Regional Memory Care Specialist, Tammy KirbyTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Case Management Inspection. This inspection is regarding an incident report received by Community Care Licensing (CCL) on 06/09/2022. LPA met with Regional Memory Care Specialist, Tammy Kirby

LPA toured Memory Care Unit. There are currently 31 residents in care. LPA observed that exits to the outdoor patio areas and the front entrance are all armed with alarms. Off of the dining area there is an alarmed door which will open but sound the alarm unless a code is entered. This door leads to a patio area. In the patio area there is a delayed egress door. Door will sound alarm for approximately 15 seconds before it pushes open. Alarms will page all staff in memory care unit.

On June 8, 2022 a resident eloped from memory care and was found sitting on the bench in front of the assisted living community across from the parking lot.


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.


Exit interview conducted with Regional Memory Care Specialist, Tammy Kirby.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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


Document Has Been Signed on 06/24/2022 04:12 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
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: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited

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87705 Care of Persons with Dementia (b)(2) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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This requirement is not met as evidenced by: Based on LPA record review, interview and osbervation, R1 was able to exit one alarmed door and one delayed egress door which poses an immediate health and safety risk to residents in care.
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2