198204069-1-29-2024-11-AS-UCOL-D36PYL-20240308104405

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204069
Report Date: 01/29/2024
Date Signed: 01/29/2024 04:24:35 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
01/23/2024 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240123102547

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:	01/29/2024
		UNANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Judith Uy-Villaruz, Executive Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not manage resident's illness while in quarantine
Staff did not meet resident's toileting needs while in quarantine
Staff do not ensure that hallways are free from hazards
Staff did not address inappropriate interaction between residents

INVESTIGATION FINDINGS:

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On 01/29/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Judith Uy-Villaruz (S1), Executive Director, and the purpose of the visit was explained. S1 and LPA toured the facility.

The investigation consisted of the following:
On 01/29/24 LPA requested and reviewed facility documents and toured the facility. LPA interviewed seven (7) out of seventy-one (71) residents and four (4) out of seventy-two (72) staff, one staff denied the interview.

Report continues, see LIC9099C

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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 3

Control Number 11-AS-20240123102547

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: 01/29/2024

NARRATIVE

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The investigation revealed the following:
Regarding the allegation: "Staff did not manage resident's illness while in quarantine". It has been alleged that staff did not assist resident one during their quarantine period.Three (3) staff have denied the allegation, while one staff denied the interview. LPA interviewed seven (7) residents (R1-R7). Five (5) out of seven (7) residents have disagreed with the allegation and feel their needs are being met, while one resident denied the interview.
Record reviews revealed that staff members have conducted routine checkups on resident one through the resident's illness quarantine from 12/14/24 - 12/19/24.
Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
Regarding the allegation: "Staff did not meet resident's toileting needs while in quarantine." It has been alleged that one resident has Irritable Bowel Syndrome (IBS) that hasn't flared up in the past few years. During resident one's (R1) illness, IBS flared up once more and resident one had terrible diarrhea. LPA interviewed four (4) staff (S1-S4). Three (3) staff have denied the allegation, while one staff denied the interview. Five (5) out of seven (7) residents have disagreed with the allegation and feel their needs are being met, while one resident denied the interview.
Record reviews revealed that R1's physician's report and the above-mentioned facilities' care plan both note as the same resident having no assistance needed with toileting.
Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Report continues, see LIC9099C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20240123102547

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: 01/29/2024

NARRATIVE

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Regarding the allegation: "Staff do not ensure that hallways are free from hazards" It has been alleged that one resident rides and parks their scooter in the hallway, which obstructs other residents' path of transportation. LPA interviewed four (4) staff (S1-S4). Three (3) staff have denied the allegation, while one staff denied the interview. LPA interviewed seven (7) residents (R1-R7). Four (4) out of seven (7) residents have disagreed with the allegation and one resident denied the interview.
Based on observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation "Staff did not address inappropriate interaction between residents". It has been alleged that one resident rides and parks their scooter in the hallway, which obstructs other residents' path of transportation. Another resident went to the subject's room, when they were answered, inappropriately, by the driver of the scooter. LPA interviewed four (4) staff (S1-S4). Three (3) staff have denied the allegation, while one staff denied the interview. One staff have had a conversation with the subject regarding this allegation. LPA interviewed seven (7) residents (R1-R7). Five (5) out of seven (7) residents have not physically observed the allegation, while one resident denied the interview.

Based on observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

An exit interview was conducted with Judith Uy-Villaruz, Exective Director (S1), and a copy of this report has been provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

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