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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608477
Report Date: 12/03/2024
Date Signed: 12/03/2024 02:34:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
08/13/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240813093655
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:
12/03/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Daisy Hernandez- Business Office DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Due to lack of staff, resident sustained a pressure injury.
Due to lack of staff, residents are falling.
INVESTIGATION FINDINGS:
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On 12.3.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Daisy Hernandez and was advised the reason for the visit.

Entrance interview conducted.

At 10 AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care.

Allegation #1: Due to lack of staff, resident sustained a pressure injury.

Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
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 6
Control Number 31-AS-20240813093655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT STUDIO CITY
FACILITY NUMBER: 197608477
VISIT DATE: 12/03/2024
NARRATIVE
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Regarding the allegation that residents in care sustained multiple pressure injuries, it was alleged that Residents #1 (R1) had beginning stages of bed sores on their bottoms. LPA did a record review on 12.3.2024 at 1 PM revealed that R1 was admitted at the facility on 8.20.2019 and was on hospice care since 4.22.2023 at Golden Time Hospice. Further review also revealed that R1 had no pressure wound upon admission to the facility. Further review also revealed that the hospice nurse would visit R1 one (1) to two (2) times a week for general visits.

LPA interview with staff on 8.19.2024 between 2:07 PM to 3:30 PM revealed residents were not being checked regularly due to being short staff. Interview with residents also confirmed that staff does not checked or rotate residents in a different positions in a timely manner.

Based on the information gathered during the course of the investigation, the allegation is deemed substantiated at this time.

Allegation #2: Due to lack of staff, residents are falling



It was alleged that due to lack of staff the residents are falling. To investigate the allegation, on 8.19.2024, LPA requested documents pertinent to the investigation, LPA interviewed twelve (12) out of seventy-one (71) residents currently residing in the facility and seven (7) staff between 2:07 PM to 3:30 PM.

Interviews with residents unanimously revealed that when residents require assistance by staff, staff is busy or occupied and the residents would just help themselves; which would result to residents falling. When staff provide assistance, staff stated that they stand next to and hold residents that need assistance wherever they want to go. Based on record review and interviews, there is enough information to verify the allegation. Therefore, the allegation is substantiated at this time.

Exit interview conducted. Copy of this report is issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
08/13/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240813093655

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:
12/03/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Daisy Hernandez- Business Office DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
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9
Due to lack of staff, residents are not showered timely
Due to lack of staff, residents are not receiving assistance while feeding
Staff handle resident roughly during hoyer lift transfers
INVESTIGATION FINDINGS:
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On 12.3.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Daisy Hernandez and was advised the reason for the visit.

Entrance interview conducted.

At 10AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care.

Allegation #1: Due to lack of staff, residents are not showered timely

Continue to LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20240813093655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT STUDIO CITY
FACILITY NUMBER: 197608477
VISIT DATE: 12/03/2024
NARRATIVE
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Regarding the allegation “Due to lack of staff, residents are not showered timely” it was alleged staff do not properly shower residents. Record review of staff training records revealed all staff had been trained on resident hygiene and bathing. Shower schedule was also given to LPA and records show that all of the residents were getting their scheduled shower. Interviews with residents revealed they receive enough assistance with showering from facility staff and an outside agency. Interviews with staff and the executive director revealed the facility revealed no hygiene issues were raised by residents, family, or visitors. Residents receive shower assistance twice a week. Based on record review and interviews, the facility meets residents’ showering needs.

Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Allegation #2: Due to lack of staff, residents are not receiving assistance while feeding

Regarding the allegation “Due to lack of staff, residents are not receiving assistance while feeding” it was alleged that because of lack of staff, the facility gives residents mechanical soft food to consume. Record review of staff training records revealed all staff are trained to properly assist with resident feeding needs. Record review of resident service plans and medical assessments revealed did not require assistance eating. LPA observed staff monitoring residents during lunch on 8.19.2024 and 12.4.2024 staff was assisting residents to eat lunch. LPA did not observe staff force feeding or rushing the residents to eat. Interviews with three (3) residents family revealed that they are happy with the staff feeding pace. Interview with business director revealed all staff monitor and assist residents with meals.

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

Allegation #3: Staff handle resident roughly during hoyer lift transfers


Continue to LIC 9099-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20240813093655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT STUDIO CITY
FACILITY NUMBER: 197608477
VISIT DATE: 12/03/2024
NARRATIVE
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On 8.19.2024, LPA requested copies of facility documents relevant to the investigation at 10:45 AM. LPA reviewed facility documents and interviewed staff and clients between 10:45 AM to 11:17 AM. LPA interview with staff on 8.19.2024 between 2:07 PM to 3:30 PM. Interviews and records reviews revealed that staff had undergone training before working and shadowing at the facility training for the hoyer lift.

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


Exit interview conducted. Copy of this report is issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20240813093655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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: 12/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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Administrator has hired and scheduled more staff regarding regulation 87411(a) and has given LPA copies of newly on-board staff training.

POC: 12.3.2024
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Based on the information obtained by the Investigator, facility did not comply with the section cited above by failing to provide the number of staff for the residents in care which poses an immediate health, safety and personal rights risk to residents in care.
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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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-CastanedaTELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6