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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802461
Report Date: 08/29/2023
Date Signed: 08/29/2023 05:45:24 PM


Document Has Been Signed on 08/29/2023 05:45 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:IVY PARK AT WOOD RANCHFACILITY NUMBER:
565802461
ADMINISTRATOR:EDITH KENNEDYFACILITY TYPE:
740
ADDRESS:190 TIERRA REJADA RDTELEPHONE:
(805) 584-8881
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:100CENSUS: 76DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Edith KennedyTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct a required annual visit. Upon arrival LPA met with Executive Director (ED) Edith Kennedy and explained the reason for the visit.

The LPA discussed the evaluation process and provided the entrance check list to Ms. Kennedy. Facility infection control plan was submitted to the Department. LPA confirmed that the facility infection control policy and procedures implemented have not changed since submission.

At approximately 1pm, LPA and Ms. Kennedy toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The fire extinguishers are inspected monthly by maintenance staff and annually by a service; they were last inspected 08/2023.

RESIDENT ROOMS: (1pm-3:30pm) The LPA observed randomly chosen residents' rooms in assisted living, terrace club and memory care. Rooms were appropriately furnished, clean and had sufficient lighting. Eight random residents were interviewed during the tour. COMMON SPACES: The lobby, activity rooms, and dining rooms were all appropriately furnished and in good condition. The LPA observed the required postings throughout the facility. Patio areas were equipped with furniture for residents' use. KITCHEN (toured 4:15pm-4:30pm): The commercial kitchen was clean and appliances all appeared operable. The facility has a sufficient supply of perishable and non-perishable food as well as an emergency supply of non-perishable food and water.

MEDICATIONs (3:30pm-4:15pm): A random selection of resident medications was reviewed. All appeared to be stored and administered according to doctors’ orders and applicable laws and regulations at this time.

Due to time constraints, the required annual inspection will continue at a later date.


Exit interview conducted. Copy of today's report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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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