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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002954
Report Date: 01/22/2025
Date Signed: 01/22/2025 01:58:18 PM

Document Has Been Signed on 01/22/2025 01:58 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:IVY PARK OF ROSEVILLEFACILITY NUMBER:
315002954
ADMINISTRATOR/
DIRECTOR:		CHAD ROGERSFACILITY TYPE:
740
ADDRESS:5161 FOOTHILLS BLVD.TELEPHONE:
(916) 780-3330
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 140CENSUS: 110DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Danette Fadollone and Neal Torres TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 01/22/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced to conduct the annual inspection. LPA met with Business Office Director Danette Fadollone during today's inspection. Facility Executive Director (ED) later joined the visit. Currently there are 110 residents of which 6 residents are receiving hospice care.

During visit LPA was informed that Chad Rogers is no longer the ED of the facility. Neal Torres is the ED now and has been since December 2024. ED stated that they did send in the paperwork to Community Care Licensing (CCL) to make the change. LPA requested for facility to resend the documents.

LPA toured facility with Business Office Director to ensure the health and safety of residents in care. LPA toured ten (10) resident rooms, medication room, bathrooms, kitchen, and activity areas. LPA observed residents in common areas participating in activities and in the dining room having lunch. The residence was found to be clean, safe, sanitary and in good condition. LPA observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents.

LPA reviewed ten (10) resident files and ten (10) staff files. Staff records reviewed indicated training completed. LPA reviewed two (2) resident medications comparing with current physician orders.

LPA requested facility to send a copy of the current liability insurance.

LPA completed the full care tool and no deficiencies was observed.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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