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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610501
Report Date: 05/01/2025
Date Signed: 05/01/2025 03:35:23 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
04/07/2025 and conducted by Evaluator Perchui Khurshudyan
COMPLAINT CONTROL NUMBER: 31-AS-20250407131128
FACILITY NAME:IVY PARK AT WEST HILLSFACILITY NUMBER:
197610501
ADMINISTRATOR:LIDIA CAUCHIFACILITY TYPE:
740
ADDRESS:9012 TOPANGA CANYON ROADTELEPHONE:
(818) 701-9550
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:90CENSUS: 63DATE:
05/01/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lidia Cauchi - Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff do not ensure that hazardous items are inaccessible to residents in care.
INVESTIGATION FINDINGS:
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On 5/1/2025 at approximately 1:00pm, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan made an unannounced subsequent visit to this facility to deliver final findings. LPA met with the Executive Director Lidia Cauchi and explained the reason for the visit.

Initial visit was conducted by LPAs Perchui Milena Khurshudyan and Angela Panushkina on 4/9/2025, and during the initial course of investigation, LPAs requested client and staff rosters. At 10:25am, LPAs requested pertinent documentation which include, but not limited to Admission Agreement, Appraisal Needs and Services, Physician Report, Unusual Incident Reports, copy of R1's Assesment report, copy of facility Plan of Operation, copy of staff training, copy of staff shift schedules, copy of staff files, copy of facility internal investigation summary, copy of staff suspension summary, etc. relevant to the investigation. At approximately 10:45am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected, and the facility is in compliance the Title 22 regulations.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
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 3
Control Number 31-AS-20250407131128
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 WEST HILLS
FACILITY NUMBER: 197610501
VISIT DATE: 05/01/2025
NARRATIVE
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Between 11:00am – 1:00pm, LPAs conducted interviews with the Executive Director, Memory Care Director, Health Care Director, three (3) staff/caregivers, six (6) out of forty-five (45) residents residing at Assisted Living, two (2) family members of residents residing at Memory Care unit and attempted to speak with six (6) out of 15 residents residing at Memory Care unit.

Allegation: Staff do not ensure that hazardous items are inaccessible to residents in care.

It was alleged that on 4/6/2025, R1 who resides in the Memory Care unit ingested dishwashing soap that was left on the kitchen counter. To investigate this allegation, LPAs conducted interviews with Executive Director and Memory Care Director and both parties interviewed confirmed that S1 diluted dishwashing soap “Dawn” in water and placed the container in the memory care unit kitchen counter unsupervised. During investigation, LPAs reviewed R1’s Physician’s Report (dated on 10/21/2024), where indicated (in Mental Condition section) Confused/Disoriented, Wondering Behavior and At Risk if Allowed Direct Access to Personal Grooming and Hygiene Items due to Dementia. ED and MCD also confirmed that R1 had several episodes of wondering around the MCU during the nighttime. Although, no witnesses were present during the incident, the ED stated that when R1 was taken to the hospital on 4/6/2025 and discharged on the same day, both ED and MCD witnessed that R1 vomited soap like solution that was similar to bubbles. Moreover, during the interview with S1, S1 admitted that because he/she had to do scheduled residents check-up rounds, the mix of dishwashing soap “Dawn” and water was left unattended and accessible to R1. Review of the facility Incident Report revealed that R1 ingested unknown substance consisting of dishwashing soap and water, 911 was immediately contacted and R1 was transferred to the hospital. Lastly, review of Plan of Operation for Dementia Care specifies on page 13, under Safety and Storage of Hazardous Materials: "The materials that may pose a risk to residents, whether through contact or ingestion, are stored securely in locked areas and remain inaccessible to residents. This includes, but not limited to: Laundry and cleaning supplies...". Review of "Dawn" detergent, the Warning label specifies the following, " Warning: Causes eye irritation, do not get in eyes. Keep out of reach of children. Rinse hands throughout after handling. First Aid treatment contains anionic and nonionic surfactants. If in eyes: Rinse cautiously with water for several minutes. Remove contact lenses if present and easy to do. Continue rinsing for 15 minutes. If eye irritation persists: Get medical attention. If swallowed, drink a glass of water to dilute". Also, review of training records confirmed that Hazardous Chemicals course was provided and completed by S1 on 12/23/2024. Therefore, based on interviews and records review this allegation is Substantiated.

Exit interview conducted and copy of this report delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250407131128
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 WEST HILLS
FACILITY NUMBER: 197610501
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/02/2025
Section Cited
CCR
87309(a)(2)(A)(B)
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Storage Space and Access:
(a)Disinfectants, cleaning solutions...shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Executive Director agreed to conduct all staff training regarding this Section.
POC cleared immediately as the proof of training got provided to LPA on the day of the visit.
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Based interviews and record review, the licensee did not comply with the section cited above. R1 ingested a chemical detergent left by S1 on the counter in a MCU. This posed an immediate health, safety or personal rights risk to persons in care.
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Request Denied
Type B
05/02/2025
Section Cited
CCR
87464(f)(1)
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Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
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Executive Direcot (ED) shall review regulations regarding supervision and dementia care. ED shall provide trainings to staff and submit plans to ensure residents do not left unsupervised. POC cleared immediately as the proof of training got provided to LPA on the day of the visit.
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Based on LPA’s observation, interview and records review, the licensee did not comply with the section cited above as R1 diagnosed as having dementia, and documented instances of wandering nighttime in the MCU, was left unsupervised. This poses a potential health and safety 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
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