198320242-4-25-2022-11-AS-EDAT-CDUA67-20220425235617

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320242
Report Date: 04/25/2022
Date Signed: 04/25/2022 11:57:32 PM

Document Has Been Signed on 04/25/2022 11:57 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 PARK AT CULVER CITY		FACILITY NUMBER:	198320242
ADMINISTRATOR:	COLLINS, BRANDON		FACILITY TYPE:	740
ADDRESS:	4061 GRAND VIEW BLVD.		TELEPHONE:	(949) 744-5200
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY:	150	CENSUS: 0	DATE:	04/25/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Brittney Buchannan		TIME COMPLETED:	02:16 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/25/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an announced visit to this facility. LPA was greeted and accompanied by applicant Brittney Buchannan during the inspection. An application was submitted to CCLD on 08/24/21. In the initial license application for a Residential Facility for the Elderly, ages 60 and above. The applicant requested a capacity of one hundred fifty (150) individuals, of which one hundred forty (140) non-ambulatory and ten (10) bedridden Structure: The facility consists of (56) bedrooms in the assisted living and (24) in the memory care unit. Each room has its bathroom. The three-story facility is situated in a residential neighborhood. The structure includes living/lobby, bistro/dining, commercial kitchen, activity/movie room, beauty salon, library, and laundry rooms. The facility offers fireplaces on each floor in common areas. The living area included sofas and a table. The kitchen includes a commercial, freezer, refrigerator, and stove. The passageways, walkways, and steps are free from obstructions. The courtyard patios are covered with tables, chairs, and umbrellas along with several water fountains. Resident's Bedroom: The facility had four (80) bedrooms for residents. All rooms include (1) a full-size bed, one (1) chair, one (1) nightstand, and one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. Evaluation Report Continues

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

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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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
MONTERY PARK, CA 91754

FACILITY NAME: IVY PARK AT CULVER CITY	FACILITY NUMBER: 198320242
	VISIT DATE: 04/25/2022

NARRATIVE

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Bathrooms:
The facility has (80) bathrooms. Each floor has public men’s and women’s restrooms. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in each resident’s room.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers, exit plan, and menu are posted and readily available for review throughout the facility. There are fire extinguishers on each floor and in the kitchen on the wall and fully charged. All rooms have a telephone line available.

Food Service:
Dishes, cups, and flatware are stored in the kitchen, inspected, and in good condition. Knives, cutlery, and other sharp kitchen utensils are stored in drawers in the kitchen. Food supply is adequately stored in the kitchen and consists of perisheable and non-perishable food.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior. Hardwired smoke detectors throughout the common areas and in each resident’s room. Carbon monoxide are available in hallways and in each resident’s room.

Water Temperature:
The water temperature is 107.9 degrees throughout the kitchen and bathrooms.

Toxins:
All toxins are locked/stored inside storage rooms.

Evaluation Report Continues

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: IVY PARK AT CULVER CITY	FACILITY NUMBER: 198320242
	VISIT DATE: 04/25/2022

NARRATIVE

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Appliances:
Stove burners, oven, microwave, washer, and dryer working. The kitchen also had small appliances which include a toaster, blenders, coffee makers, and microwaves. There are several commercial refrigerators in the kitchen. The refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. A freezer is at (45) zero degrees Fahrenheit. The facility is equipped with central air and heat throughout the common areas. Resident rooms all have individual air and heating available.

Medications, First-Aid Kit & Book:
A first aid kit is stored in the medication room has which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The resident’s medications will be stored in the same room locked and inaccessible to residents.

Resident & Staff Files:
The applicant is not handling cash resources of residents. Records for staff and residents are stored inside the Business Office.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the resident use stored in the activity, movie and library rooms.

Pool/Jacuzzi & Pets:
Pets are allowed in the facility. No jacuzzi or pool in the area.

Fire clearance:
A Fire Clearance inspection conducted on 02/01/22 with approval for a capacity for (140) non-ambulatory, and (10) for bedridden.

Rooms Inspected:
The following rooms in Memory Care were inspected #4, #6, #10, and #19. Rooms inspected in Assisted Living were: #103, #202, #214 and #301.

Evaluation Report Continues

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

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
MONTERY PARK, CA 91754

FACILITY NAME: IVY PARK AT CULVER CITY	FACILITY NUMBER: 198320242
	VISIT DATE: 04/25/2022

NARRATIVE

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Component III:
(LPA) Dabuet conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component III PowerPoint.

An exit interview was conducted, and a copy of this report has been furnished to the applicant, Brittney Buchannan. (LPA) Dabuet will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

END OF REPORT

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC809 (FAS) - (06/04)

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