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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320242
Report Date: 07/15/2022
Date Signed: 07/15/2022 04:08:24 PM


Document Has Been Signed on 07/15/2022 04:08 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 CITYFACILITY NUMBER:
198320242
ADMINISTRATOR:BRITTNEY BUCHANNANFACILITY TYPE:
740
ADDRESS:4061 GRAND VIEW BLVD.TELEPHONE:
(949) 744-5200
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:150CENSUS: DATE:
07/15/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:Brittney BuchannanTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Stephanie Cifuentes initiated a case management - Health and Safety check for the above facility. Facility currently has cases of Covid-19, but has not been declared an outbreak by the Los Angeles Department of Public Health. LPA spoke with facility receptionist, who conducted conducted a COVID-19 screening with temperature check on LPA Cifuentes. LPA's details were written on a sign in sheet. LPA was greeted by Administrator Brittney Buchannan. LPA explained the purpose of the visit was a health and safety check and was granted access to the premises.

LPA CIfuentes and Administrator Brittney Buchanan toured Evergreen, the facilities memory care unit. LPA saw signs posted regarding visitation in front lobby of facility, hand washing signs in common bathrooms with soap and paper towels. LPA saw signs posted on several doors stating either red or yellow zone and those doors also had PPE such as gowns, masks, face shield and hand sanitizer located outside. All red zone doors were closed.

LPA observed trash cans which use foot peddles. Common areas have been closed. Facility is sanitizing high touch surfaces hourly and has conducted a recent in-service training on donning and doffing of PPE. Facility is following cleaning guidelines as instructed on the cleaning product. LPA Cifuentes and Administrator Buchannan discussed cohorting, distancing of beds, the use of a barrier between cohorting residents as well as cleaning bathrooms between uses.

An exit interview conducted with Brittney Buchannan and a hard copy was provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
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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