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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320097
Report Date: 09/21/2021
Date Signed: 09/21/2021 03:34:20 PM

Document Has Been Signed on 09/21/2021 03:34 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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: 3DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:George Ayo-Ayiro, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by George Ayo-Ariyo, Administrator and the purpose of today’s visit was explained. The facility is licensed to serve 4 clients ages 18 to 59.

There are currently (3) South Central Regional Center clients in placement. All 3 clients are ambulatory. The facility is 4 bedroom, 2 bathrooms, two- story house with a 2-car attached garage. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a back yard with a covered patio for shade. The patio area contains a table with 4 chairs.

LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 119.9 F.A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: IVY HOMES
FACILITY NUMBER: 198320097
VISIT DATE: 09/21/2021
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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Foluke Ayo-Ariyo, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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Document Has Been Signed on 09/21/2021 03:34 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 09/21/2021 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY HOMES
FACILITY NUMBER: 198320097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interviews andrecord reviews the licensee did not comply with the section cited above, during todays visit LPA observed that individuals S1 and S2 did not obtain California clearances prior to working at this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2021
Plan of Correction
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The licensee agreed to remove individuals S1 and S2 during todays visit. The licensee also agreed to create a plan of correction ensuring that all staff proving care and supervision obtain California clearances prior to working at the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021


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