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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803653
Report Date: 12/09/2025
Date Signed: 12/09/2025 03:02:34 PM

Substantiated


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
11/12/2025 and conducted by Evaluator Star Stevenson
COMPLAINT CONTROL NUMBER: 21-AS-20251112084547
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:
12/09/2025
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Tedra Godfrey-Executive DirectorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Fianancial Abuse
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 12:55 PM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver findings for this complaint Investigation regarding the above allegation and met with Executive Director Tedra Godfrey.

During this investigation, the Department requested and reviewed documents, conducted interviews, and made observations. On 11/13/2025 Tedra Godfrey of Ivy Park at Rockville began an internal investigation on the same day as receiving an email from complainant regarding the above allegation. Tedra Godfrey obtained a confession from S1 that they had stolen $180 and S1 was given a Disciplanary Action Notice and Employment Termination notice from from Ivy Park at Rockville issued the same day.

In addition, an LPA interview with then former staff member S1 on 11/21/2025, had S1 admit to stealing $160 from R1 with S1 revealing they were not aware the amount was actually $180. A confession declaration was recieved by LPA from S1 indicating the theft of $160.

Continued on LIC9099-C


Substantiated
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 3
Control Number 21-AS-20251112084547
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
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 LIC9099-C

Interviews with the complainant and R1 revealed the suspicion of an earlier theft of a bottle of perfume and later, of minor snacks from R1's room. These suspected thefts were raised with the management on 08/11/2025. It was noted that the bottle of perfume that went missing from R1’s room could have been knocked into a trash can and simply taken out with the trash. At that time, without firm proof of theft, R1 was simply reimbursed by Ivy Park at Rockville for the missing bottle of perfume. Despite complainants documented concerns for a considerable theft at Ivy Park at Rockville, Community Care Licensing (CCL) received no Special Incident Report from Ivy Park at Rockville.

Based on interviews, and record review and a declaration of guilt by S1 the allegation of financial abuse (Theft) is SUBSTANTIATED A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. (See LIC9099D)

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Executive Director Tedra Godfrey and Appeal rights were given.
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 3
Control Number 21-AS-20251112084547
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2025
Section Cited
HSC
1569.269(a)(10)
1
2
3
4
5
6
7
1569.269 Enumerated Rights
(a) Residents of a Residential Care Facility...shall have the following rights...(10) to be free from neglect, financial exploitation, involuntary seclusion...
This requirement was not met as evidence by:
1
2
3
4
5
6
7
Licensee to send self-certification that the have read regulation 1569.269 Enumerated Rights of the Health and Safety Code and to provide Community Care Licensing (CCL) of the specific steps/plan they will follow in the future for investigating potential thefts in the communty and the steps they will take to notify CCL when considerable thefts are suspected to have occured.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not comply in one (1) out of one (1) instance which poses a potential health safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3