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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804017
Report Date: 02/23/2023
Date Signed: 03/23/2023 07:55:54 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/19/2022 and conducted by Evaluator Erik Gonzalez Campos
COMPLAINT CONTROL NUMBER: 21-AS-20221219120741
FACILITY NAME:IVY PARK AT SANTA ROSAFACILITY NUMBER:
496804017
ADMINISTRATOR:LYDIA GRAVELYNFACILITY TYPE:
740
ADDRESS:4225 WAYVERN DRIVETELEPHONE:
(707) 538-2590
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:114CENSUS: 90DATE:
02/23/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Administrator, Lydia GravelynTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff interferes with resident visiting at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
***Amended Report***
Licensing Program Analyst (LPA) Farhaan Sarangi arrived unannounced on to deliver amended the amended report originally dated for February 23, 2023 by Licensing Program Analyst (LPA), Erik Gonzalez Campos . LPA was greeted at the door by Business Office Manager, Debbie Spencer and was granted access into the facility.

LPA reviewed records and conducted interviews. LPA attempted to contact Resident 1’s (R1) Durable Power of Attorney (DPOA) on record. DPOA was not reachable. LPA contacted family listed in resident file who expressed no concerns regarding visitation of R1. Reporting Party (RP) also indicated that they have been allowed to visit R1 on multiple occasions. Per staff interviews, no one has been denied entry to visit R1. LPA toured memory care unit and observed R1 in the bedroom. R1 appeared to be in no distress. Based on the investigation, the allegation is unfounded meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted with administrator, Lydia Gravelyn. Report was emailed to admin. No deficiencies observed during today’s inspection.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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