197608477-10-3-2024-31-AS-NMAN-DA2SVV-20241014141319

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608477
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:08:59 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240820094809

FACILITY NAME:	IVY PARK AT STUDIO CITY		FACILITY NUMBER:	197608477
ADMINISTRATOR:	SHAHIN TAGHIZADEH		FACILITY TYPE:	740
ADDRESS:	4610 COLDWATER CANYON AVE		TELEPHONE:	(818) 505-8484
CITY:	STUDIO CITY	STATE: CA	ZIP CODE:	91604
CAPACITY:	121	CENSUS: 67	DATE:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Faraz Kashani		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Inadequate care and supervision provided by staff resulting in injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Faraz Kashani and explained the reason for the visit.

--- Inadequate care and supervision provided by staff resulting in injury.

It was alleged that an unidentified resident had five fall incidents at night during the months of July 2024 and August 2024 and that on July 28, 2024, one (01) out of two (02) of the overnight shift caregivers left early and the remaining caregiver was in the elevator leaving prior to the morning shift relief. To investigate the allegations, LPA conducted a physical plant tour at around 10:00 AM, requested pertinent documents at 11:00 AM and interviewed five (05) staff and one (01) resident between 11:30 AM to 04:30 PM.

(CONT. LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240820094809

FACILITY NAME:	IVY PARK AT STUDIO CITY		FACILITY NUMBER:	197608477
ADMINISTRATOR:	SHAHIN TAGHIZADEH		FACILITY TYPE:	740
ADDRESS:	4610 COLDWATER CANYON AVE		TELEPHONE:	(818) 505-8484
CITY:	STUDIO CITY	STATE: CA	ZIP CODE:	91604
CAPACITY:	121	CENSUS: 67	DATE:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Faraz Kashani		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility did not provide immediate emergency medical care to injured resident(s).
Staff do not promptly notify resident’s family/responsible person of condition changes.
Staff do not provide adequate assistance with activities of daily living.
Staff do not maintain the facility in a clean, safe and sanitary condition at all times.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Faraz Kashani and explained the reason for the visit.

--- Facility did not provide immediate emergency medical care to injured resident(s).
--- Staff do not promptly notify resident’s family/responsible person of condition changes.

It was alleged that after a fall incident, facility did not seek immediate medical attention for resident’s hand injury and that the responsible parties are not notified until after residents return to the facility from the hospital. To investigate the allegation, LPA requested pertinent documents at 11:00 AM and interviewed five (05) staff and one (01) resident between 11:30 AM to 04:30 PM. A review of the department’s incident reports did not reveal any such incident taking place.
(CONT. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 31-AS-20240820094809

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT STUDIO CITY	FACILITY NUMBER: 197608477
	VISIT DATE: 10/03/2024

NARRATIVE

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The facility’s incident report log does indicate that a resident sustained a fall with similar injuries but that immediate action was taken, and that resident was sent to the hospital. During interviews with staff, all staff stated, as standard practice, they conduct a full body check and seek immediate emergency medical care for all injured residents that require the attention. Staff added that after emergency medical attention is sought, they notify the responsible parties immediately. During interviews with residents, R1 stated they are not aware of any delays in seeking emergency medical attention and feel that facility notifies their responsible party promptly. LPA was unable to interview other residents.

Based on record reviews and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff do not provide adequate assistance with activities of daily living.
--- Staff do not maintain the facility in a clean, safe and sanitary condition at all times.

It was alleged that a relative found piles of dirty laundry and dried feces on the carpet and box spring in resident’s room. To investigate the allegation, LPA conducted physical plant tour at around 10:00 AM, requested pertinent documents at 11:00 AM and interviewed five (05) staff and one (01) resident between 11:30 AM to 04:30 PM. During the physical plant tour, LPA did not experience a malodor or observe any feces on the carpet, beds or anywhere else in the facility. During interviews with staff, two (02) out of five (05) staff stated they are aware of residents smearing their feces in parts of their room and have witnessed resident soiling their beds and carpets caused by attempts to change themselves and an overflow in their depends. The remaining three (03) out of five (05) staff stated they are unaware of feces on carpets and beds. All staff stated laundry does not pile up as residents have laundry service once a week minimum, or more if needed, and that residents are changed up to five (05) times a day and are checked on every two (02) hours. During interviews with residents, R1 stated they are not aware of any dirty laundry piling up and that staff do their laundry once or twice a week and are not aware of any feces on carpets and beds. LPA was unable to interview other residents.
Based on observations, record reviews and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No other health and safety hazards noted during the visit.
Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 31-AS-20240820094809

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT STUDIO CITY	FACILITY NUMBER: 197608477
	VISIT DATE: 10/03/2024

NARRATIVE

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On 08/29/2024, LPA interviewed an additional three (03) residents from around 1:30 PM - 2:30 PM.

During the physical plant tour, LPA observed three (03) caregivers and one (01) Med Tech in the memory care section. A review of the staff schedule shows facility has a minimum two (02) caregivers per shift in memory care and one (01) Med Tech in the facility that alternates between assisted living and memory care. A review of the staff time sheets revealed there were two (02) caregivers in memory care for the entire shift during the period in question. A review of the department’s incident report log shows one (01) resident with three (03) fall incidents during the period in question. A review of the facility’s records revealed the same resident had five (05) falls during the time in question, however, a complete file review revealed that the facility failed to conduct their reassessments after each incident to mitigate repeated fall incidents and determine if the resident required a higher level of care.

During interviews with staff, two (02) out of five (05) staff stated they did not witness the overnight shift leaving residents unattended but heard about it through others. One (01) out of five (05) staff stated they witnessed residents left unattended but that it was possible that as they were ascending in the elevator to start their shift, as the other care staff, which was ending their shift, was descending in the other available elevator. The remaining two (02) out of five (05) staff stated they are not aware of any residents being left unattended during the overnight shift. Regarding the unidentified resident’s five (05) fall incidents, all staff stated they are unaware of any such repeated incident during the period in question. During interviews with residents, LPA terminated interview with Resident #2 (R2) for other reasons. All other interviewed residents stated they are not aware of ever being left unattended and are not aware of any repeated fall incidents. LPA was unable to interview other memory care residents.

Based on record reviews there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No other health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20240820094809

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT STUDIO CITY	FACILITY NUMBER: 197608477
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/07/2024 Section Cited CCR 87705(c)(5)(A)	1 2 3 4 5 6 7	87705(c)(5)(A) Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia... (5) Each resident with dementia... A) When any medical assessment... ...corresponding changes shall be made... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agreed to schedule training for all staff regarding Regulation 87705(c)(5)(A). Licensee/Administrator will submit the credentials of the trainer with the scheduled training dates by 10/04/2024 and completion of training by 10/07/2024.
	8 9 10 11 12 13 14	Based on the information obtained by the Investigator, facility did not comply with the section cited above by failing to provide an updated care plan to address R1's chronic falls after each incident which poses an immediate health, safety and personal rights risk to residents 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.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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