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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610501
Report Date: 12/26/2024
Date Signed: 12/26/2024 05:25:28 PM

Document Has Been Signed on 12/26/2024 05:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HILLSFACILITY NUMBER:
197610501
ADMINISTRATOR/
DIRECTOR:		LIDIA CAUCHIFACILITY TYPE:
740
ADDRESS:9012 TOPANGA CANYON ROADTELEPHONE:
(818) 701-9550
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY: 90CENSUS: 57DATE:
12/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Alma Fuentes - Memory Care DirectorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20241119092225. LPAs met with the Memory Care Director (MCD) Alma Fuentes and explained the reason for the visit.

During the visit, LPAs interviewed Health Care Director who confirmed that they were unaware that incident with scabies were reportable. LPAs conducted review of Incident Reports and did not observe the facility submitted nor notified the Community Care Licensing (CCL) the above incident. Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the MCD that all staff members are mandated reporters and they are all responsible for reporting.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.

Exit interview conducted, appeal rights and copy of report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/26/2024 05:25 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Perchui Khurshudyan On 12/26/2024 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
12/30/2024
Section Cited
CCR
87211(a)(2)

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87211(a)(2) Reporting Requirements. Within 24 hours the licensee shall notify the licensing agency... if an epidemic outbreak, poisoning, catastrophe, or major accident which threatens the welfare, safety, or health of residents. This requirement was not meet as evidenced by:
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Executive Director will complete and submit Incident Reports to CCL Regional Office by POC date 12/30/2024.
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Based on interviews and record review the Executive Director did not comply with the section cited above by not reporting to CCL about the outbreak within the specified time, which poses/posed a potential health, safety, and personal rights risk to resident 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 Gillyard
LICENSING EVALUATOR NAME:Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2024


LIC809 (FAS) - (06/04)
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