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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850424
Report Date: 09/05/2024
Date Signed: 09/05/2024 02:10:22 PM


Document Has Been Signed on 09/05/2024 02:10 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:
565850424
ADMINISTRATOR:SKONDIN, JEANNEFACILITY TYPE:
740
ADDRESS:190 TIERRA REJADA WAYTELEPHONE:
(805) 584-8881
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:100CENSUS: 77DATE:
09/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kathleen Olson Interim Executive DirectorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management – Incident visit at 12:30 p.m. for the purpose of investigating self reported incident reports. Upon arrival, LPA met Interim Executive Director Kathleen Olson and explained the reason for the visit.

On 08/23/2024, the Department received an incident reports stating on 08/15/2024 at approx 8am, Staff #1 (S1) was observed to be handling Resident #1(R1) in a firm manner while R1 attempted to swing their arms in an agitated manner, resulting in discoloration / bruising on R1's forearms. R1 did not indicate any discomfort or additional injuries.
 
At approx 12:30pm, LPA conducted physical plant interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation.  LPA has determine further investigation is needed and will return at a later date to complete the investigation if warranted.

Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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