198320097-4-14-2022-11-AS-MVAO-CDQRDJ-20220422125601

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320097
Report Date: 04/14/2022
Date Signed: 04/14/2022 05:16:47 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2021 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20211223125020

FACILITY NAME:	IVY HOMES		FACILITY NUMBER:	198320097
ADMINISTRATOR:	AYO-ARIYO, FOLUKE		FACILITY TYPE:	735
ADDRESS:	17413 MERIMAC COURT		TELEPHONE:	(310) 753-3777
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY:	4	CENSUS: 2	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Foluke Aro-Ariyo		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff caused injuries to a client while in care

INVESTIGATION FINDINGS:

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On 4/14/2022, Licensing Program Analysts (LPA) Lourdes Montoya conducted a subsequent complaint visit to deliver findings at this facility regarding the allegation mentioned above. LPA Montoya called and conducted a risk assessment with Licensee George Ayo-Ariyo. LPA met with Administrator Ayo-Ariyo who assisted with the visit. The purpose of the visit was explained.

The investigation consisted of the following: On 12/24/2021, LPA toured the inside and outside grounds of the facility. LPA obtained copies of the following: Client #1's service records (Admission Agreement, Physician's Report, After Doctor’s Visit Summary, Need & Services/Appraisal, and Incident Reports), staff roster, and client roster. On 3/7/2022, LPA Montoya toured the facility and observed no clients and no staff were present. LPA Montoya interviewed the licensee (S1) and the administrator (S2). LPA requested and obtained Client #1’s Medication Administration Records (MAR), and other records pertinent to the allegation.

Report continued in LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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-20211223125020

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: IVY HOMES	FACILITY NUMBER: 198320097
	VISIT DATE: 04/14/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff caused injuries to a client while in care

It was alleged that staff hit client #1 in his eye and sustained a bruise and swelling under his left eye. Based on LPA’s records review, Incident Report shows that on 11/23/2021, Client #1 was reported to have a bruise on the left side of his face. Client #1 alleged that a staff hit him. The facility investigated the incident and found it to be inconclusive. Nevertheless, the alleged perpetrator (staff) was immediately suspended indefinitely. Incident Report dated 11/24/2021 indicates that the facility conducted a further investigation of the incident with the SMS transportation and it was confirmed that Client #1 had no mark on him when he was handed over for transportation on 11/23/2021 to attend a day program. Incident report dated 11/26/2021 shows Client #1 was taken to the doctor due to rashes/marks on his skin. The “After Doctor’s Visit Summary” indicated that Client #1 was seen for dermatitis and was prescribed a Triamcinolone. LPA reviewed the Informal Conference form from the South Central Los Angeles Regional Center’s (SCLARC) regarding the investigation of the alleged physical abuse involving Client #1. Based on SCLARC’s investigation, the discoloration on Client #1’s under his left eye appeared to be related to Client #1’s existing skin condition called dermatitis and not from a punch in the face.

Interviews with the Licensee (S1), the administrator (S2), and a caregiver (S3) revealed no staff caused injuries or bruises to a client and no staff hit a client in care. LPA attempted to interview Clients #1 & #2 but the interview was not completed due to lack of response from the clients. LPA called a witness (W1- Conservator for Clients #1 & #2) three times in attempt to obtain information about the allegations, but W1 did not respond to the calls. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above.

Based on LPA’s observations, interviews and record reviews, the preponderance of evidence standard has not been met therefore the above allegation, “Staff caused injuries to a client while in care”.” is found to be UNSUBSTANTIATED.

Exit interview conducted. A copy of this report was provided to Administrator Foluke Ayo-Ariyo.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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