<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200754
Report Date: 09/13/2023
Date Signed: 09/13/2023 01:52:44 PM


Document Has Been Signed on 09/13/2023 01:52 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:IVY PARK AT WALNUT CREEKFACILITY NUMBER:
079200754
ADMINISTRATOR:IRYN MACAMAYFACILITY TYPE:
740
ADDRESS:2175 YGNACIO VALLEY RDTELEPHONE:
(925) 932-3500
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:86CENSUS: 65DATE:
09/13/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Regional Operations Specialist Eugenia Smith TIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/13/2023 at 12:30 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced for a Case Management visit after Regional Operations Specialist (ROS) Eugenia Smith had contacted the LPA by phone earlier in the day. The LPA stated the purpose of the visit to the ROS upon entering the facility.

The ROS explained to the LPA that the staff had not sent the Department the Unusual Incident Reports (LIC624) after the facility ownership change occurred on 07/01/2023. Reporting of those unusual incidents and staff training in the reporting requirements and facility processes has begun and will be completed on or before 09/20/2023.

1 Type-B citation issued (refer to LIC809-D for details). Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
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 09/13/2023 01:52 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: IVY PARK AT WALNUT CREEK
FACILITY NUMBER: 079200754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2023
Section Cited
CCR
87211(a)

1
2
3
4
5
6
7
87211 REPORTING REQUIREMENTS (a) Each licensee shall furnish to the licensing agency such reports as the Department may require . . .

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee shall submit all missing LIC624 reports and train staff on the reporting requirements and facility processes for completing those and the SOC341 reports on or before the due date.
8
9
10
11
12
13
14
Based on interview of ROS, the Licensee had not sent the Department the required Unusual Incident Reports (LIC624) between 07/01/2023 and 09/12/2023.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2