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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608477
Report Date: 10/05/2024
Date Signed: 10/05/2024 03:10:24 PM


Document Has Been Signed on 10/05/2024 03:10 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
Lookup Error,
, CA



FACILITY NAME:IVY PARK AT STUDIO CITYFACILITY NUMBER:
197608477
ADMINISTRATOR:SHAHIN TAGHIZADEHFACILITY TYPE:
740
ADDRESS:4610 COLDWATER CANYON AVETELEPHONE:
(818) 505-8484
CITY:STUDIO CITYSTATE: CAZIP CODE:
91604
CAPACITY:121CENSUS: 62DATE:
10/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Christopher Redmond & Faraz KashaniTIME COMPLETED:
03:17 PM
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On 10/05/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Memory Care Director Christopher Redmond and Executive Director Faraz Kashani. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (121) non-ambulatory of which (27) may be bedridden elderly adults. The facility is approved for (20) hospice residents. Currently, there are (11) on hospice care. The facility serves residents in assisted living and memory care settings.

The facility is a four-story structure located in a residential neighborhood. It consists of the following: (91) resident bedrooms, (91) resident bathrooms, public restrooms, dining rooms, laundry rooms, activity rooms, offices, kitchen, outdoor patios, salon, and Medication rooms.

LPA Dabuet and Redmond toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #106, #110, #201, #213, #301,#318, #402 and #415. Bathrooms were operational with water temperature measured at 105.2 – 107.9 degrees F. A comfortable temperature was maintained in the facility between 74 - 76 degrees F.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. The facility has conducted Emergency Drill/Fire Drill on 09/19/24.

Evaluation Report continues LIC 809-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2024
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
Lookup Error,
, CA
FACILITY NAME: IVY PARK AT STUDIO CITY
FACILITY NUMBER: 197608477
VISIT DATE: 10/05/2024
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A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurate. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu.

LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#6 (S1-S6) personnel files were in order. The administrator certificate for Faraz Kashani #7030587740 valid through 05/01/25. The facility has a Liability Insurance Certificate valid between 05/01/24 – 05/01/25. The facility is current on CCLD annual license fees.

Advisory - Technical Assistance (see LIC 9102)

An exit interview conducted with the Executive Director Faraz Kashani, and a copy of the report is provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2024
LIC809 (FAS) - (06/04)
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