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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320097
Report Date: 03/07/2022
Date Signed: 03/08/2022 08:32:25 PM

Document Has Been Signed on 03/08/2022 08:32 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
MONTERY 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: 0DATE:
03/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:George and Foluke Ayo-Ariyo. TIME COMPLETED:
04:00 PM
NARRATIVE
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On 3/7/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiencies visit at the above facility. LPA Montoya called and conducted a risk assessment with Licensee George Ayo-Ariyo. LPA met with Administrator Foluke Ayo-Ariyo at the facility and shortly after Licensee George Ayo-Ariyo joined the visit. This purpose of the visit was explained that during a complaint investigation, deficiencies were observed.

LPA Montoya toured the facility with Licensee George Ayo-Ariyo and Administrator Foluke Ayo-Ariyo. LPA did not observe any clients and any staff present during the visit. The Licensee and Administrator stated the clients were moved out by the South Los Angeles Regional Center (SLARC) due to technical issues. LPA contacted the Regional Center and left a voicemail message. LPA consulted with LPM Kendrick and LPM Hammond.

Based on LPA's observation and interview, the licensee failed to notify CCLD when SLARC moved all the clients out and did not notify CCLD for bringing in a newly contracted vendor to manage the facility.

California Code of Regulations, (Title 22 Division 6), are being cited on the attached LIC 9099-D.

Exit interview conducted and a copy of the report was provided to Administrator Foluke Ayo-Ariyo.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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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Document Has Been Signed on 03/08/2022 08:32 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 03/07/2022 at 02:23 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
MONTERY PARK, CA 91754

FACILITY NAME: IVY HOMES
FACILITY NUMBER: 198320097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2022
Section Cited
CCR
80061(b)

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(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement was not met as evidence by:
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Licensee has informed SLARC and CCLD that the contract with a new vendor has been cancelled and the change of management was retracted. This was already corrected prior to department visit.
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Based on LPA's observation and interview, Licensee and Administrator admitted they failed to notify CCLD when all three clients were moved out by the South Los Angeles Regional Center (SLARC) from the facility due to the facility's failure to notify SLARC prior to changing the management of the facility (contracted vendor) to manage the facility. This poses a potential risk to health, safety or personal rights of clients in care.
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Type B
03/11/2022
Section Cited
CCR80064(a)(3)

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(a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by:
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Licensee agreed to review and shall adhere to Title 22 section 80064. A self-certification stetement shall be submitted to Lourdes.Montoya@dss.ca.gov by 3/14/2022.
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Based on LPA's interview, the administrator admitted she did not know that CCLD must be notified prior to changing the management of the facility and failed to report to CCLD that SLARC moved all three clients out of the facility due to a technical deficiency. This poses a potential risk to health, safety or personal rights of clients in care.
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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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022


LIC809 (FAS) - (06/04)
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