<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803653
Report Date: 07/25/2025
Date Signed: 07/25/2025 05:15:39 PM

Document Has Been Signed on 07/25/2025 05:15 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:IVY PARK AT ROCKVILLEFACILITY NUMBER:
486803653
ADMINISTRATOR/
DIRECTOR:		TEDRA GODFREYFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 356-2229
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 199CENSUS: 148DATE:
07/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Tedra GodfreyTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/25/2025 at approximately 9:30AM, Licensing Program Analyst (LPA) Ali Deniz conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. LPA was greeted by Administrator, Tedra Godfrey. The facility is a two-story building licensed for 169 non-ambulatory and 30 bedridden residents, along with a hospice waiver capacity of 20. The facility currently provides care for 148 residents, 7 of which are receiving hospice services and a dedicated memory care unit. Annual fees are current. Required postings were observed.

LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility were found to be last charged on 06/02/2025 at the time of visit. Both smoke detectors and carbon monoxide detectors throughout the facility were interconnected and inspected by an outside agency with current certification dated 10/25/2024. Elevators were found to have current inspection certification with the date of 05/22/2025. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food delivered twice per week. Food stored in the kitchen was properly stored as per regulations on this day at the time of the visit. Facility closely monitors resident diets with appropriate dietary restrictions posted on kitchen walls. Toxins are stored in designated facility storage closets located throughout the facility.

There was a supply of hygiene products and paper products available for residents. All residents’ apartments have lighting & appropriate furnishings. Water was measured at faucets in several residents’ private bedrooms and measured between 113.1- and 115.3-degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents.

Continued on LIC809-C…
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2025
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 4
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)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: IVY PARK AT ROCKVILLE
FACILITY NUMBER: 486803653
VISIT DATE: 07/25/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809…

Medications located in medication rooms in both assisted living and memory care unit were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Medication management staff also conduct full medication record audits once per month. During the tour, residents observed interacting with staff in common spaces, watching television in their private bedrooms, participating in various activities with Activities Director and mingling in the dining hall with family and amongst each other. Residents are visited by family frequently and interact with one another in the dining area, common spaces as well as in resident private apartments. There is an ample amount of outdoor space and seating for residents on the front corridor and center patio for additional leisure. The facility conducts emergency disaster drills on a monthly, quarterly and annual basis all of which focus on various emergency types and include both staff and residents. Last monthly fire drill conducted on 07/11/2025

At approximately 12:45PM, LPA reviewed 10 resident records and found 10 of out 10 residents have current care plans, signed admission agreements, and physician's report on file. Medication records are thorough and contain physician's orders for each resident. LPA reviewed 6 staff records. 2 out of 6 records did contain documentation of completed training records as required, evidence of first aid training was current. Administrator stated the other 2 out of 6 staff are not working now and they won’t come back to work until they complete their training hours. 1 out of 6 staff have missed training ours. The administrator stated that when the management company changed three months ago the management company took all the staff and residents records with them. The facility is working on maintaining all the needed documents back again. (Technical Violation Issued). 1 out of 6 staff are working in the maintenance department and not required to have a first aid certificate per regulation.

LPA reviewed the facility emergency disaster plan. Facility has supplies enough to operate for more than 72 hours in an emergency. Administrator, Tedra Richardson-Godfrey, Administrator Certification 7004281740 is valid through 10/21/2026.

Updated copies of the following documents were requested for the facility file and are to be submitted to CCL by due date of 08/05/2025:
LIC 308 Designated
LIC 500 Personnel Summary
LIC 9020 Register of Facility Client’s/Resident’s
Copy/Proof of Updated Certificate of Liability Insurance

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4