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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609532
Report Date: 03/01/2024
Date Signed: 03/01/2024 12:12:31 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
08/23/2023 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20230823121458
FACILITY NAME:IVY PARK AT WEST HILLSFACILITY NUMBER:
197609532
ADMINISTRATOR:DAVIS, DINAFACILITY TYPE:
740
ADDRESS:9012 TOPANGA CANYON ROADTELEPHONE:
(818) 701-9550
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:90CENSUS: 45DATE:
03/01/2024
UNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Dina DavisTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff did not safeguard a resident's personal records while in care
Staff do not have access to a resident's personal records
INVESTIGATION FINDINGS:
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In conjunction to complaint control #31-AS-20240229113340, Licensing Program Analysts (LPAs) Ray Comer and Michael Cava conducted a subsequent complaint visit to investigate the above allegations. LPAs met with the administrator, Dina Davis, and advised her of the complaint. The initial visit to this complaint was made by LPA Melissa Spaeth on 08/30/23. At that time, Resident 1's (R1) records were not available for LPA Spaeth's review. Licensee was given the time to present these records to LPA Spaeth. To this date, R1's records could not be presented by the license. Pursuant to title 22, Division 6, Chapter 8, the allegations are Substantiated. Citation issued on the 9099D. Ms. Davis was advised. Appeal rights and a copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
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 2
Control Number 31-AS-20230823121458
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 WEST HILLS
FACILITY NUMBER: 197609532
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
87506(a)
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Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement was not met as evidenced by: LPA Spaeth initiated the complaint
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As POC, the licensee will provide R1's records to the Licensing Agency by COB 03/15/24.
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investigation on 08/30/23. At the time of the visit, R1's records were not readily available for review, at the facility. Through today, 03/01/24, R1's records are still not available.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC9099 (FAS) - (06/04)
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