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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804395
Report Date: 08/07/2026
Date Signed: 08/07/2026 01:19:30 PM

Document Has Been Signed on 08/07/2026 01:19 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:
486804395
ADMINISTRATOR/
DIRECTOR:		GODFREY, TEDRAFACILITY TYPE:
740
ADDRESS:4625 MANGELS BLVD.TELEPHONE:
(707) 862-2222
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 199CENSUS: 144DATE:
08/07/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Tedra Godfrey- Applicant RepresentativeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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At approximately 09:30 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a Pre-Licensing inspection for a Change of Ownership (CHOW) and was greeted Applicant Representative Tedra Godfrey. (AR)

Facility received a fire clearance on 11/17/2025 to care for 199 residents including 169 non-ambulatory and 30 bedridden residents. Bedridden residents can be served on both 1st and 2nd floors. Facility is noted to have emergency evacuation chairs at the top of each fire hardened stairwell.

The current facility has a hospice clearance for 20 residents with a plan to care for 30 hospice residents. Facility has an Emergency and Disaster plan, as well as Infection Control plan on file.

At approximately 10:15 AM, LPA initiated a tour of the facility with AR and observed the following:

The facility staffs a receptionist and seating area at the main entrance. The two-story entry way has views of the larger of two Courtyards, Activity room, large Dinning room and separate cafe-style dinning area, as well as a centralized seating area with piano.

A centrally located resident Mail Room has required Compliant, Theft Policy, Resident Rights and Resident Council Rights posters. Hallways throughout the property have 4 fire extinguishers each that were all observed to be fully charged and last inspected in June of 2026. Hallways were observed to be unobstructed and exit doors with audible wander alerts were clearly marked. Stairwells were noted to have emergency pull cords

Continued on LIC809-C

Bethany Moellers
Star Stevenson
DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2026
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)
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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: 486804395
VISIT DATE: 08/07/2026
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Continued from LIC809

Facility has two courtyards in assisted living and a 3rd courtyard in memory care. Facilities delayed egress doors were observed to be label properly and functioning correctly. Facility has an activity room, large theater room, sitting library and upstairs hair saloon. Upstairs portion of the building is accessible by multiple elevators and stairs.

Facility cleaners and toxins are stored in locked housekeeping supply rooms. Housekeeping carts are lockable and were found to be locked while in use. LPA observed plenty of perishable and nonperishable foods. The kitchen and dining area clean and well maintained. Water temperature measured within regulation between 105 and 120 degrees F in various resident bathrooms in both Assisted Living and Memory care. LPA observed the facility has a hard wired fire alarm system and automatic fire sprinkler system which passed inspections on 11/17/2025 and 11/06/2025 and will soon undergo repeat annual inspections.

Medication is centrally stored and locked in a dedicated medication room in the assisted living and memory care sections of the building. Resident medical records are also kept locked and inaccessible.

The facility has multiple pull station fire alarm with audio/visual alert, and all resident bathrooms have pull cords for alerting staff for assistance. Residents also receive a pendant to keep with them.

Facility has the required 7 days non-perishable and 2 days perishable food on hand. Foods in both the refrigerator and freezer rooms of the central kitchen were noted to be clean and foods well labeled, including foods that had been taken out of the original commercial packaging.

Based on their knowledge shown, the AR has successfully completed the Component lll Orientation section of the application process. Current Executive Director Godrey has been the appointed administrator of this facility for approximately 1.5 years prior to this ownership change, and has shown a thorough understanding of Title 22 regulations and applicable Health and Safety Codes.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC809 (FAS) - (06/04)
Page: 3 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: 486804395
VISIT DATE: 08/07/2026
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Continued from 809-C

LPA and AR discussed the following items:
· The need for updated Liability Insurance once new licensed is issued.
· Guardian background clearances and associations - Applicant understands that all current staff members associated to Ivy Park at Rockville (486803653) will need to be transferred and associated to new facility license (486804395) once approved.

LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status.

Exit interview conducted with Tedra Godfrey (Applicant Representative)



Copy of report discussed and provided. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC809 (FAS) - (06/04)
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