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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 11/06/2025
Date Signed: 11/06/2025 01:01:27 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2025 and conducted by Evaluator Star Stevenson
COMPLAINT CONTROL NUMBER: 21-AS-20251014134258
FACILITY NAME:IVY PARK AT ROCKVILLEFACILITY NUMBER:
486803653
ADMINISTRATOR:TEDRA GODFREYFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVDTELEPHONE:
(707) 356-2229
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:199CENSUS: DATE:
11/06/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH: Administrator Tetra Godfrey. TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff do not ensure facility plumbing is in good repair
INVESTIGATION FINDINGS:
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At approximately 10:30 AM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver findings for this complaint Investigation regarding the above allegation and met with Administrator Tetra Godfrey.

During this investigation, the Department requested and reviewed documents, conducted interviews, and made observations. LPA determined that Ivy Park at Rockville has its own maintenance department that uses both an electrical plumbing snake, as well as manual snake for clogged or slow toilets. In addition, each housekeeper cart has a plunger on board to respond to clogged toilets, and the maintenance team keeps additional plungers on hand in the maintenance room.

LPA obtained evidence of an in-house work order system called "TELS" being used to respond successfully to a clogged toilet on 08/16/2025 with resolution in18 minutes and again on 06/17/2025 with successful resolution in 13 minutes.
Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20251014134258
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/06/2025
NARRATIVE
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Continued from LIC9099
Staff interviews revealed that once a resident, a responsible party, friend or other staff identify a maintenance problem, the problem is immediately entered into the TELS system, and a member of the maintenance team sets out to fix the problem or will call an outside vendor if needed. Finally, an interview with R1 revealed that in fact, the maintenance staff had quickly responded to their toilet concern and that their toilet was never truly clogged but just slow to flush and R1 reports always being able to use their toilet and never having to use a toilet outside their room. LPA interviewed resident (R2) in an adjoining room to R1 which revealed they never had a problem with their toilet during the same time frame and that the maintenance team was quick to respond to their requests for repairs.

Based on observations made, records reviewed, and interviews conducted, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Tetra Godfrey - Administrator

Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2