198204069-7-17-2024-11-AS-JHAD-D7HMSY-20240725095243

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204069
Report Date: 07/17/2024
Date Signed: 07/17/2024 02:31:12 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/28/2024 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240628130119

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: 72	DATE:	07/17/2024
		UNANNOUNCED	TIME BEGAN:	01:03 PM
MET WITH:	Richard Alvarenga		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff did not administer medication as prescribed.

INVESTIGATION FINDINGS:

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On 07/01/24, at 1:23pm, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Hugo Lemus, Health Services Director, and Richard Alvarenga, Memory Care Director. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegation mentioned above.

The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R6). Resident Roster (Dated: 06/13/2024) Staff Roster (Dated: No Date), ID/Emergency Information (Dated: 03/27/2024), Physicians Report (Dated: 01/31/2024 & 07/02/2024), Medication Administration Record (Dated: 06/01/24-06/30/2024) were obtained from the facility for R1.

The investigation revealed the following: Allegation #1- Facility staff did not administer medication as prescribed.

Report continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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-20240628130119

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: IVY PARK AT SANTA MONICA	FACILITY NUMBER: 198204069
	VISIT DATE: 07/17/2024

NARRATIVE

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The details of the complaint alleged that R1 was admitted to the hospital after the facility was unable to provide R1 with R1’s insulin medication for at least 5 days. On 07/17/24, from 11:00am-2:00pm, LPA interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. 4 of 4 staff denied the allegation that the Facility staff did not administer medication as prescribed. 4 of 4 staff interviewed stated that R1 did receive all medications as prescribed by R1’s doctor. Staff further stated that R1 received R1’s insulin injections the five prior days before the resident went to the hospital.

R1 stated that R1 had self-administered R1’s insulin injection but that there may have been a problem with the Pen-Injector giving the proper amount of the medication. R1 stated that R1 did not blame the staff, it might have been a faulty Pen-Injector. R1 further stated that when the insulin was injected it looked as if the proper dose was being administered. LPA reviewed the Medication Administration Record (Dated: 06/01/24-06/30/24) for R1 and found that the resident self-administered R1’s insulin and it was witnesses by staff.

LPA interviewed R1-R6 about the allegation and 6 of 6 residents that were interviewed denied the allegation that Facility staff did not administer medication as prescribed. All residents interviewed stated that the staff does administer their medication as prescribed by their physician and have not missed any doses of their medication.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Facility staff did not administer medication as prescribed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted with Richard Alvarenga, Memory Care Director, and a hard copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC9099 (FAS) - (06/04)

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