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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208915
Report Date: 06/16/2025
Date Signed: 06/16/2025 04:12:51 PM

Document Has Been Signed on 06/16/2025 04:12 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:IVY PARK AT SAN LAURENFACILITY NUMBER:
157208915
ADMINISTRATOR/
DIRECTOR:		RICE, DOUGLASFACILITY TYPE:
740
ADDRESS:5300 HAGEMAN RDTELEPHONE:
(661) 218-8333
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY: 68CENSUS: 61DATE:
06/16/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Brenda Myers, Interim Administrator TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On June 16, 2025, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced case management visit at the above facility for the purpose of discussing a recent incident report.

On June 12, 2025, an incident report was submitted to CCL regarding a resident who recently eloped from the facility . On June 12, 2025 a resident (R1- see confidential names list attached) left her bedroom by way of the window. After removing the screen R1 climbed out and wandered to property adjacent to the facility at approximately 6:00 AM. R1 then contacted her family who in turn contacted the facility who verified she was not in her room. Staff immediately returned her to the facility and arranged for one on one care until it is determined that she is no longer an immediate risk to elope. A medical appointment is scheduled for this week to determine what if any medical factors are affecting her behavior. The family has been to the facility and understands the action taken and has no immediate concern over the care she is receiving. The facility has also installed new window 'warden locks' on all memory care windows. R1 had removed the previous window lock but the new ones are metal and should not be as easily removed.

Discussion was had regarding the night staff and room checks. The NOC shift previously would do room checks every two hours. Since this incident room checks have been changed from every 2 hours to every hour.

A citation under Title 22 is being issued at today's visit. The plan of correction has already been put in place and will be cleared at today's visit as well. See attached deficiency page.
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Rachel A Bruce
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/16/2025 04:12 PM - It Cannot Be Edited


Created By: Rachel A Bruce On 06/16/2025 at 03:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: IVY PARK AT SAN LAUREN
FACILITY NUMBER: 157208915

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2025
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by
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Facility has installed new locks on the resident bedroom windows and regarding R1 have arranged one on one care until further notice. Plan of correction will be cleared at today's visit.
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R1 eloped out of her bedroom window and subsequently called her family to inform them she had 'gotten out'. R1 was immediately returned to the facility. Elopement poses an immediate risk to the health and safety of residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Rachel A Bruce
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2025


LIC809 (FAS) - (06/04)
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