191601433-3-2-2022-11-AS-AJKK-CD5KV7-20220403081348

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191601433
Report Date: 03/02/2022
Date Signed: 03/02/2022 12:59:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2022 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220301092036

FACILITY NAME:	IVY HOME, THE		FACILITY NUMBER:	191601433
ADMINISTRATOR:	RAFAEL BRAVO		FACILITY TYPE:	740
ADDRESS:	1322 12TH STREET		TELEPHONE:	(310) 458-8006
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90404
CAPACITY:	6	CENSUS: 3	DATE:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Susanna Valdez, Caregiver		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility is not allowing residents to have visitors.

INVESTIGATION FINDINGS:

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On 03/02/2022, Licensing Program Analyst (LPA) Troy Agard initiated a complaint investigation at the above facility to address the following allegation. LPA Agard was met with caregiver, Susana Valdez and explained the purpose of the visit was to gather information regarding this complaint.

LPA requested copies of the following documents: resident and staff roster.

The investigation consisted of the following: LPA Agard toured the facility, conducted interviews with the administrator, a resident, staff, witnesses and reviewed visitation list.

On 03/02/2022 LPA Agard delivered findings.

continue on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220301092036

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY HOME, THE	FACILITY NUMBER: 191601433
	VISIT DATE: 03/02/2022

NARRATIVE

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Regarding the allegation: Facility is not allowing residents to have visitors. It’s being alleged that the facility has a sign stating no visitors are allowed. Thus, not allowing visitors. The investigation revealed the following: S1 denied the allegation to be true. “We are allowing visitors, that sign was something that was put up a long time ago and honestly forgotten about. If licensing tells us to remove it then we will. Check the visits logs, we are not denying visitors. S2 denied the allegation to be true. “Yes, we allow visitors. I take their temperature and record it here. R1 denied the allegation to be true. When asked if they receive visitors they confirmed, “yes.”

During interviews with W1 & W2 they both denied the allegation to be true. W1 states, “well I live 3000 miles away and surely would have been upset if I was not allowed in. I visited back in November (2021) and did not have any issues. I think earlier, during the pandemic they may have been more strict.” W2 states, “I have never been denied. We are always able to see our relative. During a visit there is usually 6-8 of us at a time. My mother visits my relative every other day. We have never had a problem.

LPA observed a sign on facility front gate stating, “Due to Covid-19, no visitors allowed with the exception of home health staff.” LPA had sign removed by Administrator.. LPA observed a visitor log at the facility’s front entrance along with visiting hours.

Based on LPA observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of the report was given.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

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