198204069-10-3-2023-11-AS-SLEO-CWA23A-20231003170200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204069
Report Date: 10/03/2023
Date Signed: 10/03/2023 05:02:06 PM

Document Has Been Signed on 10/03/2023 05:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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:	10/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Judith Uy-Villaruz		TIME COMPLETED:	05:10 PM

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On 10/3/2023, Licensing Program Manager (LPM) Coronel & Licensing Program Analyst (LPA) Leandro, conducted an unannounced Required – 1 Year Inspection and met with Judith Uy- Villaruz Executive Director.
Facility is licensed to serve one hundred (100) residents. The facility also has an approved hospice waiver for ten (10) residents. The Annual Licensing Fees are current. The facility consists of three (3) floor levels.

The Executive Director accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 116.8 & 118.4 Fahrenheit. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the industrial kitchen area and observed a two-day supply of perishable and a seven day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. One carbon monoxide detector was tested in the first-floor hallway and smoke alarms get tested once a year by the fire department. Both devices were functional. LPA observed that all bedrooms and hallways are equipped with a carbon monoxide and smoke detector.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT SANTA MONICA	FACILITY NUMBER: 198204069
	VISIT DATE: 10/03/2023

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5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

5 resident records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans.

No Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted. A copy of this report was provided to the Executive Director.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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