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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204069
Report Date: 10/19/2024
Date Signed: 10/19/2024 05:16:57 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
02/26/2024 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240226091417
FACILITY NAME:IVY PARK AT SANTA MONICAFACILITY NUMBER:
198204069
ADMINISTRATOR:VILLARUZ, JUDITH UYFACILITY TYPE:
740
ADDRESS:1312 15TH STTELEPHONE:
(310) 899-1976
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:100CENSUS: DATE:
10/19/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Cyr Mongo TIME COMPLETED:
11:37 AM
ALLEGATION(S):
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Staff did not provide adequate supervision, resulting in a resident slipping in the shower.
Staff did not meet a resident's hygiene needs.
Staff did not maintain the facility in a clean and sanitary condition.
Facility is in disrepair.
Facility has mold.
Staff yelled at a resident.
Facility does not provide a safe environment for a resident.
INVESTIGATION FINDINGS:
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On 10/19/24, the Community Care Licensing (CCL) associate made an unannounced visit to the facility and was greeted by Sales & Marketing Director (S10: Cyr Mongo). The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations.

An initial investigation visit was conducted by (CCL) associates on 03/04/24 who was met by Administrator (S1: Matthew Ryan, Executive Director). (CCL) associates toured the facility’s physical plant for health and safety purposes of residents in care. (CCL) associates obtained copies of the following documents: Facility Resident Roster, Personnel Report LIC 500, Facility Order Review Report, Facility Rent Roll Detail Report, Facility Work Order Reports, Facility Average Daily Occupancy and Census Report, Facility Staff Training Records, Resident #1 (R1’s) care plan, email correspondences and other records pertinent to the allegations mentioned in this complaint.
(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
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 6
Control Number 11-AS-20240226091417
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: 10/19/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:
Allegation #1: Staff did not provide adequate supervision, resulting in a resident slipping in the shower.
Allegation #2: Staff did not meet resident’s hygiene needs.
The details of the complaint alleged due to inadequate supervision resident #1 (R1) slipped in the shower. It is reported that due to ineffective staffing (R1’s) hygiene needs are not met caused by delay and refusal from staff.

On 03/04/24, between 09:46 am – 10:30 am, the Department interviewed staff #1 (S1) who stated these allegations are false. (S1) claimed (R1's) needs have special requirements. (R1) when using the shower water gets everywhere. (R1) requested for a non-slip in the bathroom but wanted the chemical applied to the whole bathroom and the facility complied to (R1’s) request. (R1) felt hygiene needs were not being met and requested for new toilet did not like the toilet that is provided, and it had nothing to do with facility staff not being able to provide basic services timely. (R1) fell in the shower on 01/15/24, with the assistance and supervision of (R1’s) private care provider present. (S1) indicated that (R1) maintains independence and required no assistance with personal grooming and hygiene needs. (R1) requires assistance with set up of showering material assisted by (R1’s) private care provider. (R1) has been evaluated did not require status checks all according to (R1’s) Facility’s Evaluation Report (dated: 01/15/24).

On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (3) out (6) staff #4, #5 and #8 (S4-S5 and S8) were able to confirm of (R1’s) fall and that (R1) received immediate assistance. (S8) indicated that (R1) had the tendency to take showers 3 or 4 times daily and during the fall, (R1’s) private care giver was present when the incident occurred. (S5) reported that (R1) at time refused assistance in the shower twice on 01/15/24 which probably contributed to (R1’s) fall. According to (S4), an incident report was created, and that staff responded to (R1’s) fall right away.



Five (5) out of six (6) staff #5-#9 (S5-S9) were interviewed who stated to have had direct care with (R1) and assisted with (R1’s) hygiene needs. As described by (S6), (R1) is challenging when it comes to hygiene assistance. Nevertheless, when requested by (R1), the proper care will be provided.

On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (4) out (6) residents #3- #6 (R3-R6) affirmed they are independent and did not need staff assistance nor have experienced a fall.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20240226091417
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: 10/19/2024
NARRATIVE
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(R2) who is dependent on assistance from the care staff was complimentary of services received from the caregivers and claimed to have never experienced a fall.

(R1) was interviewed and claimed to have worked in an aviation and familiar with walking on slicks surfaces. (R1) said rather than non-slip strips or bath mats, (R1) requested a water based liquid that can be applied to the floor to prevent slipping. (R1) claimed that management did not take the suggestion seriously. (R1) confirmed that (R1) fell while in the shower and assistance was provided by care staff. But did not want to expand further on the incident. (R1) claimed have dispatched for help by pulling the pendant and emergency cord several time and that care staff refused to help (R1). (R1) said the staff are selective on who they want to assist and did not want to help with putting on shoes and did not have orders to help with this sort of service.

As a result of reviewing (R1’s) Facility Evaluation Report (dated: 01/15/24), Facility Care/Shift Notes (dated: 01/15/24-01/20/24), Care Plan (dated: 12/18/23) Preplacement Appraisal Information (dated: 11/22/23), Physician Report (dated: 11/22/2023), revealed (R1) is in independent and can self-care, (R1) refused bathing support and (R1) repeatedly pressed for call pendant and that care staff helped, (R1) experience a fall and 911 was dispatched but refused hospital services. The Department reviewed Facility Staff Training Records (dated: 03/2023 – 03/2024) Resident Rights in Assisted Living, Assisting with Personal Care, Essential of Resident Rights, Providing Customer Services, revealed evidence of adherence to regulatory requirements. Based on the gathered information, there is no evidence to support the allegations mentioned above.

Allegation #3: Staff do not maintain in a clean and sanitary condition.


Allegation #4: Facility is in disrepair.
Allegation #5: Facility has mold.

The details of the complaint alleged resident #1 (R1’s) room is unclean, unsanitary and in disrepair. It is reported that blood stains on carpet, water leaks, toilet not flushing, lighting in bathroom is non-operable and the shower has mold. It is noted that nothing is being done to address these issues by the facility.

On 03/04/24, between 09:46 am – 10:30 am, the Department interviewed (3) out (3) staff #1- #3 (S1-S3) all denied these allegations. (S1-S3) stated every maintenance request from (R1) are fasted tracked.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20240226091417
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: 10/19/2024
NARRATIVE
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(R1’s) carpet have been cleaned, but still not to (R1’s) satisfaction. The lighting has to do with light plug outside, with a lock on it. (S1) had a staff unlock that for (R1) to use a grill. There is no evidence of mold in (R1’s) room. (S1) reported an incident with the water overflow into (R1’s) living/kitchenette lead from (R1’s) shower caused water and carpet bubbled but no mold. (S1) indicated Suttles Plumbing arrived on 02/23/24 and noted in their service report no mold. (S1) stated (R1) would see (S2) in the hallway and requests plentiful time for me to have (R1’s) carpet cleaned. (R1’s) carpet was cleaned every week. (S2) indicated there were a slew of maintenance requests in dealing with (R1’s) room. All were followed through by maintenance right away.

On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (6) out (6) staff #4-#9 (S4-S9) were not able to corroborate these allegations. Two (2) out of the six (6) staff had heard of some mold issues in (R1’s) room, but it was discredited when professional plumbing services assessed the repairs. (S4-S9) stated if maintenance issues occur, it is resolved by the maintenance team instantly.

On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (5) out (6) residents #2- #6 (R2-R6) who indicated no repairs with leaks, toilets, carpet, or lighting issues. Five (5) out of six (6) reported to have had no mold issues. (R1) was interviewed and claimed the water leak came from poor installed shower. The carpet is black from mold left from walls. (R1) claimed to have observed a bucket with plumbing parts in it had mold all over and did not feel safe.

On 03/04/24 between 12:52 pm – 1:30 pm, the Department inspected (R1’s) room did not observed stains on carpet, no water leaks, no issues with toilet or lighting. The Department did not observe any evidence of mold. The Department observed (R1’s) room clean, safe, sanitary and in good repair. The Department observed housekeepers were on site conducting housekeeping duties.

As a result of reviewing the facility’s Work Orders (dated: 01/01/24 – 03/03/24), it revealed service repair requests by (R1) have been accelerated in priority status and were addressed. There is no evidence that facility failed to act with reasonable care or duty. The Facility Evaluation Report (dated: 01/15/24), it is noted (R1’s) room is not free of clutter and obstacles. (R1) is also provided additional housekeeping 1x/ day (bed making, empty trash, straighten room) beyond standard services. Based on the gathered information, there is no evidence to support the allegations mentioned above.

Allegation #6: Staff yelled at a resident.


Allegation #7: Facility does not provide a safe environment for a resident.

(Evaluation Report continues LIC 9099-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20240226091417
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: 10/19/2024
NARRATIVE
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The details of the complaint alleged that resident #1 (R1) is verbally mistreated by staff. It is reported that with the verbal mistreatment it is considered a harassment and that (R1) is not provided a safe environment. It reported that (R1) was being harassed by staff and management with office calls.

On 03/04/24, between 09:46 am – 10:30 am, the Department interviewed (3) out (3) staff #1- #3 (S1-S3) all refuted these allegations. (S1) reported there have been no verbal altercation between staff and (R1) and there has been no harassment from staff or management. (S2-S3) claimed when responding or interacting with (R1), they have always acted in a professional manner. (S2-S3) described (R1) with high standards and is determined that all work orders are addressed promptly. (S1-S3) asserted the residents are provided a safe environment.

On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (6) out (6) staff #4-#9 (S4-S9) were not able to validate these allegations. (S4-S9) all indicated that they have not observed or experienced any staff verbal mistreatment or altercations with residents. (S7) claimed to have a good relationship with (R1) and communication is cordial. (S4-S9) reported residents are assisted to ensure their safety and are provided a safe and healthful environment.



On 03/04/24, between 10:50 am – 12:52 pm, the Department interviewed (5) out (6) residents #2- #6 (R2-R6) declared they have never experience or witness any verbal mistreatment of staff on residents. (R4-R5) stated they heard some staff voices raised, residents that have hearing loss, one must raise voices to be heard. Nevertheless, they have not heard anything negative coming from staff. (R2-R6) expressed the facility provided a safe environment for residents in care. (R2-R6) claimed to have never felt unsafe or at risk living at this facility.

(R1) was interviewed and claimed staff have verbally mistreated (R1) and (R1) has seen other victims subjected to the same abuse. However, (R1) was unable to provide names of individuals involved nor did not want to further elaborate on the matter. According to (R1), (R1) felt unsafe at the facility as staff makes everyone do their physically therapy up and down the hallway. A contradiction to what was reported about (R1) who felt unsafe due to staff mistreatment or harassment with office calls.

As a result of reviewing (R1’s) Facility Evaluation Report (dated: 01/15/24), it revealed (R1) is in independent and can self-care and did not require status check.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20240226091417
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: 10/19/2024
NARRATIVE
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The report noted (R1) is severely hearing impaired and that requires additional staff time and assistance with routine communication. Facility Progress Notes (dated: 01/15/24), (R1) can independently provide self-care, however, it is noted a change in behavior repeated inquiry for assistance with activity with use of call pendant/pull cord (R1) needing to be heard for attention, comfort, and reassurance. Based on the gathered information, there is no evidence to support the allegations mentioned above.

Based on information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.



An exit interview was conducted with Cyr Mongo (Sales & Marketing Director), and copies of the reports were provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6