197608477-8-29-2024-31-AS-NMAN-D93SLE-20240913135814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608477
Report Date: 08/29/2024
Date Signed: 08/29/2024 03:48:49 PM

Unsubstantiated

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
08/16/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240816091353

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:	08/29/2024
		UNANNOUNCED	TIME BEGAN:	01:52 PM
MET WITH:	Faraz Kashani, Executive Director		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff neglect led to resident's death.

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.

--- Staff neglect led to resident's death.

It was alleged that facility was not able to give Resident #1 (R1) their medications as prescribed due to staff not having keys to the medication cart overnight. It was also alleged R1 had multiple falls and that both the lack of overnight medication and falls lead to R1’s death. 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.

(CONT. 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: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

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 31-AS-20240816091353

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: 08/29/2024

NARRATIVE

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A review of R1’s death certificate states the cause of death is Alzheimer’s. The facility’s medication administration records revealed R1 was given their medications as prescribed. A review of the department's incident report records does not indicate that R1 had multiple falls during the period in question. During interviews with staff, all staff stated that all shifts, including the overnight shift, have access to the medication cart at all times. During interviews with Resident #2 (R2), they stated their spouse R1 did not sustain multiple falls, was given medications as prescribed and does not feel that there was any neglect or mishandling leading to R1’s death.

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 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: 08/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC9099 (FAS) - (06/04)

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