198204069-8-28-2025-11-AS-SCIS-DLTUXX-20250924155903

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204069
Report Date: 08/28/2025
Date Signed: 08/28/2025 10:02:47 AM

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
06/18/2025 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 11-AS-20250618125738

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: 71	DATE:	08/28/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Clifton Douyon- Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are mismanaging residents medication.
Staff did not have resident re-evaluated before placement into memory care
Staff are not providing activities for memory care residents
Staff did not provide adequate transportation for resident
Staff did not ensure residents room was clean
Staff did not ensure resident had bedding
Staff are not allowing resident to participate in activties with husband

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 8/27/2025, at 10:30 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a complaint investigation and deliver findings for the alleged allegations. LPA identified herself and met Clifton Douyon -Administrator who was informed of the purpose of the visit.

On 6/23/2025 LPA conducted an interview with Clifton Douyon-Administrator and requested copies of the following documents: Resident 1-Resident 2 (R1-R2) Client File: Physician report not dated(R1) R2 dated 4/4/2025,Pre-placement dated 4/11/2025, Admission Agreement 4/16/2025,assessment needs and service plan summery dated 4/14/2025,incident reports, Case Notes, Medication Logs, and ID/Emergency information.

The investigation consisted of the following:

Continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025

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 4

Control Number 11-AS-20250618125738

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: 08/28/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 8/27/2025, Licensing Program Analyst (LPA) conducted interviews with five staff members (S1–S5). LPA attempted to interview Residents R1 and R2; however, they were not present at the facility at the time of the investigation. Interviews were successfully conducted with Residents R3, R4, and R5.
In addition to the interviews, the LPA reviewed relevant documentation, including email correspondence, assessments and re-assessments for R2, and the exit ledger following the termination of the admission agreement initiated and signed by R1.

The investigation revealed the following:

#1 Allegation: Staff are mismanaging residents’ medication.

On 8/27/2025, LPA conducted interviews with five (5) staff members (S1-S5) 5 out of 5 staff members stated that all residents receive their medications as prescribed by their physicians.
LPA attempted to interview R1 and R2 however they were not at the facility at the time of the investigation and the interviews conducted with R3, R4 and R5 stated they have received their medications as prescribed by their physicians.

#2 Allegation: Staff did not have resident re-evaluated before placement into memory care.

On August 27, 2025, Licensing Program Analyst (LPA) conducted interviews with five (5) staff members (S1–S5). During the interviews, S1-S2 staff members stated that Resident 2 (R2) had been re-evaluated on 5/16/2025 and it was determined that R2 required a higher level of care. S3,S4 and S5 could not confirm or deny that R2 was re-evaluated prior to moving to memory care.

LPA reviewed a Resident Change Form dated May 27, 2025, which documented that R2 was being transferred to the memory care unit with an effective date of May 19, 2025. The form was signed by R1 prior to R2’s relocation.

LPA attempted to interview Resident 1 (R1) and Resident 2 (R2); however, both were not present at the facility at the time of the investigation.

Continued

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20250618125738

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: 08/28/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

#3 Allegation: Staff are not providing activities for memory care residents

LPA conducted interviews with staff members S1- S5, and 5 out of 5 stated residents, including those in the memory care unit, are provided with activities such as exercises, karaoke and wheel of fortune.

LPA attempted to interview Residents R1 and R2; however, they were not present at the facility during the investigation. Interviews conducted with Residents R3, R4, and R5 stated they are provided with activities such as Bingo, fitness, and movies. LPA also observed an activity schedule posted for both the assisted living and memory care unit.

#4 Allegation: Staff did not provide adequate transportation for resident.

LPA conducted interviews with staff members S1-S5, and 5 out of 5 stated that residents are provided with transportation for appointments with doctors. However, the transportation van has not been available for a while, but alternate transportation is provided for those by utilizing Uber, or Lyft.

LPA attempted to interview Residents R1 and R2; however, they were not present at the facility during the investigation. Interviews conducted with Residents R3, R4, and R5 indicated that there has not been anyone to transport residents but if transportation is needed the staff will utilize Uber or Lyft.

#5 Allegation: Staff did not ensure residents room was clean

LPA conducted interviews with staff members S1-S5, and 5 out of 5 stated that residents’ rooms are cleaned daily or as needed but a deep cleaning is done once a week. LPA attempted to interview Residents R1 and R2; however, they were not present at the facility during the investigation.

Interviews conducted with Residents R3, R4, and R5 stated staff cleans their room daily. LPA toured the facility, room 313-B and 217 which appeared to be clean and free of odors.

Continued

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20250618125738

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: 08/28/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

#6 Allegation: Staff did not ensure resident had bedding.

LPA conducted interviews with staff members S1-S5, and 5 out of 5 stated that when residents are admitted into the facility, they are responsible for providing their own bedding unless residents indicate assistance is needed upon admission. Licensing Program Analyst (LPA) attempted to interview Residents R1 and R2; however, both were not present at the facility during the investigation.

Interviews were conducted with Residents R3, R4, and R5. All three residents stated that they were not provided with bedding upon admission and were informed that they were responsible for supplying their own bedding.

#7 Allegation: Staff are not allowing residents to participate in activities with their husband.

The Licensing Program Analyst (LPA) conducted interviews with staff members S1-S5. 5 out of 5 stated that all residents are allowed to participate in activities, either individually or in groups. When specifically asked about Residents R1 and R2, staff members S1-S5 confirmed that the two residents always participated in activities together, even after R2 was relocated to the memory care unit.

The LPA attempted to interview Residents R1 and R2; however, both were not present at the facility during the time of the investigation. Interviews conducted with Residents R3, R4, and R5 stated they are allowed to participate in activities if they choose to do so. Additionally, they reported that they did not know Residents R1 or R2.

Based on interviews conducted, documents reviewed and observations the above allegations are found to be Unsubstantiated; meaning that 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.

An exit interview was conducted where this report was discussed and provided to Clifton Douyon Administrator at conclusion of the visit with appeal rights.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4