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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 12/09/2025
Date Signed: 12/09/2025 03:09:08 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
11/05/2025 and conducted by Evaluator Star Stevenson
COMPLAINT CONTROL NUMBER: 21-AS-20251105083126
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: 147DATE:
12/09/2025
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Tedra Godfrey-Executive DirectorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff did not provide resident's responsible party with itemization of additional fees charged.
INVESTIGATION FINDINGS:
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At approximately 12:45 PM Licensing Program Analyst (LPA) Star Stevenson arrived to deliver findings regarding the above allegation and met with Tedra Godfrey-Executive Director.

During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff did not provide resident’s responsible party with itemization of additional fees charged”

The responsible party alleged that the facility would not provide them with a timely written update of additional care fees to be charged.

LPA learned through record review that complainant had written notice of a “Legacy Care Fee” structure for residents in place when a new managment company took over, as well as access to an updated Admissions agreement and the Resident Assessment of care points assigned to R1. In addition, the responsible party had written notice as of April 1st, 2025, of the care fees that would be assessed Legacy residents under the new management at Ivy Park at Rockville.
Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
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-20251105083126
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: 12/09/2025
NARRATIVE
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Continued for LIC9099

Complainant acknowledged an understanding that care costs could increase and fluctuate depending on the care needs of R1. LPA learned through interviews that management had met with Complainant on 4 occasions, to go over care costs and answer questions. Complainant did report hearing conflicting expected care costs from S1 and S3, an assertion this LPA found to be credible. However, although the complaint was received on 11/04/2025, by 11/05/2025, LPA received an email from complainant noting they had on-line access to the amounts due for the next month and that, “The amount shown appears to be reasonable and manageable” Because of conflicting information on whether staff provided the resident’s responsible party with itemization of additional fees charged, the 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.

Exit interview conducted. Copy of report discussed and provided to Executive Director Tedra Godfrey. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2