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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920222
Report Date: 11/20/2024
Date Signed: 11/20/2024 12:54:39 PM

Document Has Been Signed on 11/20/2024 12:54 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 AT BLUE OAKS, THEFACILITY NUMBER:
315920222
ADMINISTRATOR/
DIRECTOR:		DOYLE, ANGELIQUEFACILITY TYPE:
740
ADDRESS:275 ROSEVILLE PARKWAYTELEPHONE:
(916) 432-2878
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 157CENSUS: 0DATE:
11/20/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Angelique DoyleTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility announced on 11/20/24 to conduct a Pre-licensing referencing the CARE inspection tool. LPA met with the Executive Director and explained the purpose of the visit.

LPA toured the interior and exterior of the facility and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, outdoor areas and The Gardens (memory Care) area, In the areas toured no immediate health, safety concerns observed.

There are currently no residents or staff present.

Component III review is waived as the applicant has other facilities.

The facility is in significant compliance.

License pending approval.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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