198204069-3-6-2024-11-AS-UCOL-D3LMH3-20240322093651

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204069
Report Date: 12/27/2023
Date Signed: 03/06/2024 11:20:27 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2023 and conducted by Evaluator David Espana

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231220105042

FACILITY NAME:	IVY PARK AT SANTA MONICA		FACILITY NUMBER:	198204069
ADMINISTRATOR:	VILLARUZ, JUDITH UY		FACILITY TYPE:	740
ADDRESS:	1312 15TH ST		TELEPHONE:	(310) 899-1976
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90404
CAPACITY:	100	CENSUS: 70	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Administrator, Judith Uy-Villaruz		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility is not reporting a COVID-19 outbreak as required.

INVESTIGATION FINDINGS:

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This is an amendment of the investigation report delivered on 12/27/2023, the purpose of this amendment is to provide additional information and it does not change the investigation findings. On 12/27/2023 at 8:45 am Licensing Program Analyst (LPA) David España conducted a subsequent complaint investigation at the above facility to address the following allegations due to needs further investigation of control number 11-AS-20231220105042. LPA España met with Executive Director Judith Uy-Villaruz and explained the purpose of this visit was to deliver findings on control number 11-AS-20231220105042 complaint. Upon arrival at the facility, LPA España conducted a risk assessment at the facility entrance. Based on the assessment, the facility is not clear of Covid-19 infection. The investigation consisted of the following: during today's visit, LPA with Executive Director Judith Uy-Villaruz confirmed positive cases at the facility as of 12/27/2023. It has been determined that there are a total Seven (7) out of Seventy (70) residents still positive with COVID-19. LPA reviewed and received from the Administrator the COVID 19 community tracker as of 12/27/2023 at 9:00 am. REPORT EVALUATION REPORT CONTINUES ON LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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 11-AS-20231220105042

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT SANTA MONICA	FACILITY NUMBER: 198204069
	VISIT DATE: 12/27/2023

NARRATIVE

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LPA interviewed Seven (7) out of Seventy (70) residents in person. LPA interviewed Seven (7) out of Seventy-One (71) staff in person. LPA interviewed Seven (7) out of Seventy (70) residents in person that could not confirm the date when they were advised of COVID-19 present at the facility. LPA confirmed with the Administrator that the facility reported COVID-19 cases on 12/22/2023 to CCLD. Per interview with the Administrator, there was no need to report cases to CCLD due to no outbreak. LPA confirmed with the Administrator that as of 12/21/2023 there has been only Seven (7) total positive cases active out of the Nineteenth (19) residents that were positive at the facility. LPA confirmed with the Administrator that as of 12/27/23 there were Seven (7) quarantine. Per the Administrator the precaution or quarantine guidelines are that after the 6^th day if a person does not show fever (symptoms) they, the person who was positive may come outside of quarantine, however, must be masked for Ten (10) days per guidelines. LPA confirmed with the Administrator that there are Twenty-Two (22) out of Seventy-One (71) staff member currently working at the time of visit. The investigation revealed the following: Facility is not reporting a COVID-19 outbreak as required. Based on observation, interview, and record review, the licensee did not comply with the section cited above. At 10:00 AM LPA observed the facility did not report COVID-19 outbreak as required, which poses/posed a potential health, safety or personal rights risk to persons in care. LPA attempted to interview on 12/22/2023 all positive residents and LPA was provided three (3) out of the total positive cases to interview from the Administrator, however, due to safety concerns LPA felt he could not maintain a suitable conversation (illness). LPA interviewed Seven (7) out of Seventy (70) residents and all Seven (7) residents stated they were notified. LPA and interviewed Seven (7) out of Seventy-One (71) staff members who stated they informed the Administrator of any positive cases. LPA requested by phone and in person Mitigation Plan Report from the Administrator, for purpose of record. LPA has also observed the facility tracking system (excel sheet) and entryway COVID-19 surveillance testing for every person entering the facility. LPA observed staff members provide N95s to be used when entering the facility. LPA reviewed the Administrator tracking system dated with results of “Symptom Start Date: 11/18/2023; 11/23/2023; 12/17/2023; 12/17/2023; 12/17/2023; 12/17/2023; 12/18/2023; 12/19/2023; 12/19/2023; 12/19/2023; 12/19/2023 and 12/22/2023.” LPA has observed and discussed PIN 20-48-ASC Coronavirus Disease 2019 (COVID-19) Mitigation Plan Report and Training with the Administrator.
EVALUATION REPORT CONTINUES ON LIC 9099-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231220105042

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT SANTA MONICA	FACILITY NUMBER: 198204069
	VISIT DATE: 12/27/2023

NARRATIVE

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Additionally, LPA is citing the following regulation: Title 22, Division 6, Chapter 8, Article 04., Operating Requirements, 87211 Reporting Requirements which states “Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours…” “…to the licensing agency and to the local health officer when appropriate.”

Regarding the allegation: “Facility is not reporting a COVID-19 outbreak as required.” Based on LPA’s observations, interviews and record reviews, the preponderance of evidence standard has been met therefore the above allegation is found to be substantiated. California Code of Regulations, Tittle 22 are being cited were assessed please see LIC 9099D.

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with the Administrator Judith Uy-Villaruz whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231220105042

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT SANTA MONICA	FACILITY NUMBER: 198204069
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/05/2024 Section Cited CCR 87211(a)(2)	1 2 3 4 5 6 7	87211(a)(2) Reporting Requirements: (2) Occurrences, such as epidemic outbreaks... residents... shall be reported within 24 hours... licensing agency... when appropriate.This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will review Title 22, Division 6, Chapter 8, Article 04., Operating Requirements, 87211 Reporting Requirements, and submit a written plan detailing how the Administrator will ensure that incidents/deaths are reported to CCL office as required according to the regulation. The plan is due to the CCL office by POC date David.espana@dss.ca.gov.
	8 9 10 11 12 13 14	Based on record reviews and interviews, the licensee failed to ensure that COVID-19 cases were reported to the license agency within 24 hours for positive cases between 11/18/2023-12/22/2023 . Which poses a potential health, safety, or personal rights risk to persons in care.	8 9 10 11 12 13 14
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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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC9099 (FAS) - (06/04)

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