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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320097
Report Date: 11/20/2024
Date Signed: 11/20/2024 02:47:02 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
11/14/2024 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241114082922
FACILITY NAME:IVY HOMESFACILITY NUMBER:
198320097
ADMINISTRATOR:AYO-ARIYO, FOLUKEFACILITY TYPE:
735
ADDRESS:17413 MERIMAC COURTTELEPHONE:
(310) 753-3777
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:4CENSUS: 4DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Oluwarotimi JohnsonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff hit resident.
INVESTIGATION FINDINGS:
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On 11/20/24, at 9:00am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Oluwarotimi Johnson, House Manager. LPA explained the purpose of this visit is to gather information about the complaint, gather facility files, and deliver findings for the allegation mentioned above.

The investigation consisted of the following: The department investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S4) and clients (C1-C2). Client Roster (Dated: 12/24/2021) Staff Roster (Dated: 10/23/2024), SIR (Dated: 11/11/2024), Admission Agreement (Dated: 04/29/20222), Physician Report (Dated: 12/08/2023 & 11/08/2024), Individual Program Plan (Dated: 05/04/2023), Face Sheet (Dated: 05/22/2023), Client Development Evaluation Report (Dated: 05/04/2023) and ID/Emergency Information (Dated: 04/03/2022) were obtained from the facility.

Complaint Investigation Report continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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 2
Control Number 11-AS-20241114082922
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 HOMES
FACILITY NUMBER: 198320097
VISIT DATE: 11/20/2024
NARRATIVE
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The investigation revealed the following: Allegation- Staff hit resident.

The details of the complaint alleged that the client (C1) was hit by a staff member with an open hand on 11/11/2024. On 11/20/24, from 10:00am-2:00pm, LPA interviewed staff (S1-S4) and clients (C1-C2) regarding the allegation. 3 of 4 staff denied the allegation that the Staff hit resident. One staff stated that they were not there the morning of the incident and had no knowledge of it. 3 of 4 staff (S1-S3) interviewed stated that C1 was angry and agitated that day because C1 wanted to go to C1s old day program. The staff (S1-S3) stated that they tried to explain to C1 why it was not possible to go to the old program because that contract had expired and that C1 had a new day program to go to. S1 asked C1 what was the reason that C1 did not want to go to the day program, C1 told S1 that someone hit C1. S1 asked when did they hit you? C1 stated, they hit me right now. S1-S3 stated that they were present during the conversation, and no one touched the client, C1 simply made up that story to get C1s way.

LPA reviewed the Special Incident Report (Dated:11/11/2024) detailing what happened on 11/11/2024 and the Individual Program Plan (Dated: 05/04/2023) that states C1 has a history of maladaptive behavior, physical aggression, and disruptive behavior that interferes with social participation.

LPA interviewed C1-C2 about the allegation and 2 of 2 clients that were interviewed denied the allegation that Staff hit resident. All Clients (C1-C2) interviewed stated that they have not been hit or witnessed any staff member hitting any clients. They further state that they are happy with the care and supervision they are receiving from the staff.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff hit resident. 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 deficiencies were cited.

An exit interview was conducted with Oluwarotimi Johnson, House Manager, and a hard copy of this Complaint Investigation Report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2