198204069-3-26-2025-11-AS-JHAD-DFQV79-20250414161044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204069
Report Date: 03/26/2025
Date Signed: 03/26/2025 02:05:35 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
03/17/2025 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20250317151337

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: 67	DATE:	03/26/2025
		UNANNOUNCED	TIME BEGAN:	09:57 AM
MET WITH:	Executive Director Clifton Douyon		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff are not meeting resident's dietary needs.
Staff isolated resident.

INVESTIGATION FINDINGS:

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On 03/26/25 10am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Executive Director (ED) Clifton Douyon as the purpose of today’s visit was explained.

The investigation consisted of the following: On 03/26/25 LPA Villegas obtained copies of the staff and resident roster, menus for February 2025-March 2025, alternative menus, list of residents with modified diets/dietary restrictions, Dietary report, Serv safe training certificate for staff #1-2 (S1-S2), and list of residents placed on isolation in the last 30 days. On 03/26/25 LPA requested the following documents for resident #1 (R1); facesheet, admission agreement dated:01/31/2018, physicians report dated:04/26/2022, needs and service plan dated:01/25/25, preplacement appraisal dated: 01/31/2018, diet clarification form dated: 2/28/25, and power of attorney documents dated 06/13/2013. On 03/26/25 from 10:20am- 12:15pm LPA conducted Interviews with resident # 1-6 (R1-6), and between 12:15pm-1:30 pm LPA conducted interviews with ED and staff #1-5 (S1-S5). On 03/26/25 LPA toured the facility kitchen and observed the dinning room during lunch time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

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-20250317151337

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: 03/26/2025

NARRATIVE

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The investigation revealed the following:
allegation: Staff are not meeting resident's dietary needs.
It is being alleged that staff stopped grinding food for resident in care. On 03/26/25 from 10:20am- 12:15pm LPA conducted Interviews with resident # 1-6 (R1-6), 5 of 6 residents interviewed denied the allegation above, and reported having no issues with the meals being served. 1 of 6 residents interviewed confirmed the allegation above and stated the dinner provided is not being grinded. On 03/26/25 12:15pm-1:30 pm LPA conducted interviews with ED and staff #1-5 (S1-S5), 6 of 6 staff interviewed denied the allegation above and reported meals are provided as indicated by Doctors orders. 6 of 6 staff interviewed reported there is a board in the kitchen that list what diet is needed per resident. On 03/26/25 LPA toured the facility kitchen, LPA observed a large board next to kitchen line that has residents picture along with dietary restrictions and/or modified diets. LPA also observed alternative menus placed in the dinning room that residents can choose from if they want a different meal then what is being served. On 03/26/25 LPA conducted a file review and observed R1 to have a diet clarification form dated: 2/28/25, which indicates a mechanical soft, finely chopped diet. LPA observed there was an order for a swallowing evaluation to assess for any potential concerns related to diet, however it is documented that the resident and responsible party refused.

Allegation: Staff isolated resident.
It is being alleged that facility staff placed a resident on isolation without informing the resident why.
On 03/26/25 from 10:20am- 12:15pm LPA conducted Interviews with resident # 1-6 (R1-6), 5 of 6 residents interviewed denied the allegation above. 1 of 6 residents interviewed confirmed the allegation above and reported being on isolation for 3 weeks without reason. On 03/26/25 12:15pm-1:30 pm LPA conducted interviews with ED and staff #1-5 (S1-S5), 6 of 6 staff interviewed denied the allegation above and reported isolation occurs when it is order by a Doctor. On 03/26/25 LPA conducted a file review and observed documented communication dated 2/28/25 that resident would be placed on isolation for medical condition from 02/28/25-03/04/25 per MD, documentation also indicated responsible party was notified of the isolation order.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC9099 (FAS) - (06/04)

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