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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202847
Report Date: 06/17/2022
Date Signed: 06/17/2022 03:28:43 PM

Document Has Been Signed on 06/17/2022 03:28 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:IVY PARK AT SAN JOSEFACILITY NUMBER:
435202847
ADMINISTRATOR:POST, SARAFACILITY TYPE:
740
ADDRESS:4855 SAN FELIPE ROADTELEPHONE:
(408) 223-1312
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 140CENSUS: 98DATE:
06/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jayden BettencourtTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management visit ,and met with Memory Care Director (MCD) Jayden Bettencourt.

On 6/3/2022, the Department received an Unusual Incident Report from facility regarding a resident (R1) eloped from facility. The Department conducted an interview on 6/3/2022 and requested the resident's physician report.

On 6/6/2022, the Department received resident's physician report.

Based on the record reviewed on 6/6/2022, and the interview conducted on 6/3/2022, the resident is not allowed to leave unassisted.

A deficiency was cited today. See LIC809-D. Exit interview was conducted with MCD This report and LIC809-D were provided to MCD for record.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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 06/17/2022 03:28 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 06/17/2022 at 08:25 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT SAN JOSE
FACILITY NUMBER: 435202847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2022
Section Cited
CCR
87464

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Basic Services (f)Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). Health and Safety Code section 1569.2(c) provides:(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance …”
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Administrator to submit plan of staff training regarding providing supervision or assistance to residents who can’t leave facility unassisted to CCL by POC date.
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This requirement was not met as evidenced by:

Based on interview, and records review, the facility did not provide the necessary assistance to R1 who can’t leave facility unassisted when R1 left the facility. This poses an immediate risk to the health and safety of resident in care.
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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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


LIC809 (FAS) - (06/04)
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