191601433-11-18-2023-11-AS-DESA-CXPR6N-20231118114501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191601433
Report Date: 11/18/2023
Date Signed: 11/18/2023 11:45:09 AM

Document Has Been Signed on 11/18/2023 11:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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:	11/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:41 AM
MET WITH:	Ivan Bravo, Administrator		TIME COMPLETED:	12:35 PM

NARRATIVE

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On 11/18/2023 at 8:30 am Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arriving at the facility, LPA met Ivan Bravo, Administrator who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections.

LPA met with Administrator Ivan Bravo and explained the purpose of today’s visit. The facility is a Residential Care Facilities for the Elderly (RCFE) licensed for six (6) non-ambulatory clients. Currently, there is three (3) residents residing in the facility, all 60 or older. The facility is a two-story structure located in a residential neighborhood. It consists of the following: four (4) resident rooms downstairs with two bathrooms, living room, dining room, kitchen, outside laundry room. The second floor consists of three (3) staff bedrooms, an office, and spare room. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. LPA and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed.

Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. There are no security bars or weapons on the premises. The water temperature measured at 108.8 degrees Fahrenheit and 120 degrees Fahrenheit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Cleaning supplies and toxins, sharps objects are stored in locked kitchen drawers and cabinets, locked and not accessible to clients. The kitchen was inspected and there is a 2-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly.
Facility Evaluation Report continued LIC-809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

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

LIC809 (FAS) - (06/04)

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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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY HOME, THE	FACILITY NUMBER: 191601433
	VISIT DATE: 11/18/2023

NARRATIVE

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Two (2) fully charged fire extinguishers were found in both upstairs and downstairs hallway that were charged, smoke detectors, and carbon monoxide were operable.

During the visit, LPA observed that the facility has an approved Mitigation Plan Report on file with CCLD.LPA observed staff were wearing face coverings, all mandated inspection control posters were posted.

There were deficiencies cited during this inspection visit.

Staffing - Type B: 1569.618(c)(3) - Licensing Program Analyst (LPA) David España. and Ivan Bravo, Administrator did not observe First Aid Training for Staff #1-#3. Resident Rights/Information - 87468(c)(2)(A) - Licensing Program Analyst (LPA) David España. and Ivan Bravo, Administrator did not observe PUB 475 20"X26" posted at the main entryway of the facility. Disaster Preparedness - Technical Violation: 1569.695(a)(5) - Licensing Program Analyst (LPA) David España and Ivan Bravo, Administrator did not observe LIC 610 Emergency Disaster Plan.

Advisories are on attached 9102.

An exit interview was conducted, and a copy of this report and appeal rights was provided to Ivan Bravo, Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/18/2023 11:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY HOME, THE	FACILITY NUMBER: 191601433
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensing Program Analyst (LPA) David España. and Ivan Bravo, Administrator did not observe First Aid Training for Staff #1-#3, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2023
	Plan of Correction
1 2 3 4	Administrator stated will audit all resident files for completeness, and shall complete/submit copy of written record of First Aid Training for Staff #1-#3 on provided by POC date david.espana@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

LIC809 (FAS) - (06/04)

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