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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200754
Report Date: 07/12/2023
Date Signed: 07/12/2023 04:49:31 PM


Document Has Been Signed on 07/12/2023 04:49 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: DATE:
07/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:IRYN MACAMAYTIME COMPLETED:
05:15 PM
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On 07/12/2023 at 8:50 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced at facility for required annual inspection. LPA informed Administrator (ADM) Iryn Macamay of the purpose of the visit.

During the Inspection, ADM toured the facility inside and outside with LPA. LPA reviewed files of 5 residents and interviewed 4 clients and 4 staff members.

No citations were issued during the inspection.

Exit interview conducted with ADM and a copy of this report was provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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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