198204069-7-5-2023-11-AS-UCOL-CW3UCN-20230927152813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204069
Report Date: 07/05/2023
Date Signed: 07/05/2023 04:55:15 PM

Unsubstantiated

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
06/29/2023 and conducted by Evaluator Antonine Richard

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230629102252

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: 60	DATE:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	08:19 AM
MET WITH:	Judith UY-Villaruz		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Due to lack of adequate supervision, resident was pushed by another resident leading to head injury.

INVESTIGATION FINDINGS:

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On 07/05/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannnounced complaint visit at this facility, LPA was greeted by Executive Director Judith Uy-Villaruz. LPA explained the purposed of today's complaint investigation.

The investigation consisted of the following: during today's visit LPA Richard with Excecutive Director Villaruz conducted the toured of the facility, interviewed six (6) out of sixty (60) Residents and interviewed six (6) out fifteen (15) staff. LPA also conducted records reviews of staff,facility and resident records.

The investigation revealed the following: it is being alleged that "due to lack of supervision, a resident was pushed by another resident that led to a head injury. During the tour of the faciltity LPA observed resident R1 present at the facility, R1 did not have visible traces off prior head injury. LPA interviews revealed the following: six (6) out of sixty (60) Residents were interviewed but none were able to provide any answers. LPA interviewed six (6) out fifteen (15) staff none of them witnessed the incident and only heard R1 yelled someone push her.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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-20230629102252

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: 07/05/2023

NARRATIVE

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Based on the information collected, record reviews and interviews, the Department found no evidence to support the allegation mentioned in this complaint.

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 deficiency was cited during this visit.

An exit interview was conducted with Judith UY-Villaruz, and a copy of this report was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

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