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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320097
Report Date: 10/04/2023
Date Signed: 10/04/2023 04:18:23 PM

Document Has Been Signed on 10/04/2023 04:18 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 HOMESFACILITY NUMBER:
198320097
ADMINISTRATOR:AYO-ARIYO, FOLUKEFACILITY TYPE:
735
ADDRESS:17413 MERIMAC COURTTELEPHONE:
(310) 753-3777
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 4DATE:
10/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Oluwarotimi Johnson, House ManagerTIME COMPLETED:
04:30 PM
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On 10/04/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required visit using the CARES inspection tool. LPA was met by Oluwarotimi Johnson, House Manager (S2) and later by George Bolade Ayo-Ariyo, licensee (S1) and the purpose of today’s visit was explained. Upon entry, LPA was instructed to sign in on the daily visitor logbook. The facility is licensed to serve four (4) clients ages 18 to 59, Ambulatory only.

There are currently four (4) South Central Regional Center clients in placement. All 4 clients are ambulatory. The facility is a 4 bedroom, two (2) bathroom, two-story house with an attached 2-car garage. There is a back yard with a covered patio for shade. The patio area contains a table with 2 chairs.

LPA Leon and S2 toured the physical plant. There are no bodies of water or firearms/ammunition on the premises. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Beds and bedding were in good condition, adequate lighting was provided, storage for client personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were clean and operational. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and LPA Leon observed there is enough perishable and non-perishable food available which is stored properly. All medications are centrally stored and inaccessible to clients.

One (1) Fire extinguisher, located centrally nearby the kitchen on the 1st floor, was properly charged. Seven (7) smoke detectors were operational and were observed to be inter-connected properly. The two (2) carbon monoxide detectors were both operable. The last fire drill was conducted on 08/02/23, at 6:18PM, with all 4 clients and three (3) staff and lasted 3 minutes and 58 seconds

Report Continues, see LIC809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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 HOMES
FACILITY NUMBER: 198320097
VISIT DATE: 10/04/2023
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LPA advised the House Manager to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (cdss.ca.gov) Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies observed.

An exit interview was held and a copy of the report was provided to Oluwarotimi "Akin" Johnson, House Manager.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC809 (FAS) - (06/04)
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