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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320242
Report Date: 05/28/2024
Date Signed: 05/28/2024 04:31:26 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2022 and conducted by Evaluator Regina Cloyd
COMPLAINT CONTROL NUMBER: 11-AS-20221020162028
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: 78DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Armida UchiyamaTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Resident sustained an unexplained fracture while in care.
Staff did not observe a change in resident’s condition.
Staff left resident unattended in soaking wet diaper for extended period.
Staff did not report unusual incidents involving resident.
Staff do not provide proper food services to resident.
Facility does not have a vehicle to transport wheelchair-bound residents.
INVESTIGATION FINDINGS:
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On 05/28/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPAs met with Business Office Director Armida Uchiyama and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA reviewed Resident Roster, Facility Personnel Report, October 2022 Memory Care Schedule, and interviewed the Sous Vide Chef and Lead Server. On 01/13/2023, Investigator Dennis Seng completed his investigation on the first and second allegations: “Resident sustained an unexplained fracture while in care,” and “Staff did not observe a change in resident’s condition”. The investigation consisted of the following: During the investigation, Inspector Seng reviewed the service request, incident report, supporting documents, medical records, photographs, completed LIS/File Review/Treatment Plan, and interviewed the Administrator, (2) Residents, (2) Med-Techs, (2) Caregivers, (1) LVN, (1) Lead Care Provider, and (4) Witness.

Continue to LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 11-AS-20221020162028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PARK AT CULVER CITY
FACILITY NUMBER: 198320242
VISIT DATE: 05/28/2024
NARRATIVE
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On 07/26/2023 around 10:00AM Licensing Program Analyst (LPA) Jose Calderon initiated an investigation for Ivy Park at Culver City Facility for the allegation complaints listed above. Today’s complaint investigation was conducted face to face Administrator Brittney Buchannan. During today’s visit, LPA Jose Calderon conducted face to face with Administrator Brittney Buchannan. LPA Calderon interviewed S1-S5 and R1-R9 for complaint.On 10/24/2022 around 10:00AM Licensing Program Analyst (LPA) Jose Calderon initiated an investigation for Ivy Park at Culver City Facility for the allegation complaints listed above. Today’s complaint investigation was conducted face to face Administrator Brittney Buchannan. During today’s visit, LPA Jose Calderon conducted face to face with Administrator Brittney Buchannan. LPA Calderon and Administrator Buchannan toured the facility including all common areas, kitchen, dining room and the Memory Care Unit. LPA Calderon requested copies of the following: Staff and Resident Roster, SIR reports for current complaint, physician report, needs and service plan, UCLA x-rays records and any other medical records, Color picture of right hand and finger for R1, maintenance records for facility van, meal plan for facility to be given to LPA Calderon by 10/24/2022.

Allegation(s):
Resident sustained an unexplained fracture while in care.

The investigation revealed the following: Regarding the allegation " Resident sustained an unexplained fracture while in care,” it is being alleged that on 10/17/22 Resident #1 (R1) sustained a broken finger while in care. Interview with Caregiver (Contact #5) indicated that on 10/15/22, Contact #5 completed a full body check and found no issues with R1. Interview with Caregiver (Contact #6) indicated that on 10/16/22, Contact #6 conducted a body check with MedTech (Contact #7) and found no issues with R1. Record review reveals on 10/17/22 5:00 AM, another MedTech completed an internal incident report for an abrasion on R1’s right elbow only. Interview with MedTech (Contact #8), indicated that on 10/17/22 early AM, R1’s private companion reached out to Contact #8 to assess R1’s finger. Contact #8 called R1’s doctor and family member. On 10/18/22, x-rays were completed and R1 was diagnosed with a fractured right index finger. Interview with the Administrator indicated that R1’s fracture was reported on 10/17/22. R1’s private caregiver told Contact #8 and Contact #8 called R1’s doctor.

Continue to LIC9099-C.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20221020162028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PARK AT CULVER CITY
FACILITY NUMBER: 198320242
VISIT DATE: 05/28/2024
NARRATIVE
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 Regarding the allegation “Resident sustained an unexplained fracture while in care,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiency was cited for this allegation.

Allegation(s):
Staff did not observe a change in resident’s condition.

The investigation revealed the following: Regarding the allegation "Staff did not observe a change in resident’s condition,” it is being alleged that on 10/17/22, Resident #1 (R1) black and blue index finger was not reported by staff. Interviews indicated that on 10/15/22, the facility’s caregiver (Contact #5) completed a full body check and found no issues with R1. On 10/16/22, the facility’s caregiver (Contact #6) conducted a body check with MedTech (Contact #7) and found no issues with R1. Record review revealed that on 10/17/22 5:00 AM, another MedTech completed an incident report for an abrasion on R1’s right elbow only. Interviews indicated that on 10/17/22 early AM, MedTech (Contact #8) was contacted by R1’s private companion to assess R1’s finger. Charting notes reveal that Contact #8 observed the swelling and bruising at 7:00 AM on 10/17/22. Contact #8 called R1’s doctor and family member. Interview with the Administrator indicated, staff conduct routine body checks while clients showered and superficial body checks during diaper changes. Administrator indicated that the staff does not do intrusive body checks where they would undress clients and inspect their skin daily. Regarding the allegation “Staff did not observe a change in resident’s condition,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiency was cited for this allegation.

Continue to LIC9099-C

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20221020162028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PARK AT CULVER CITY
FACILITY NUMBER: 198320242
VISIT DATE: 05/28/2024
NARRATIVE
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Allegation(s):
Staff left resident unattended in soaking wet diaper for extended period.

The investigation revealed the following: Regarding the allegation “Staff left resident unattended in soaking wet diaper for extended period,” it is being alleged that Resident #1 (R1) was left in a wet diaper one year ago (2021). Interviews indicated that 4 out of 5 staff members change residents with incontinence needs an average of 3 times per shift. The Administrator indicated that residents are checked every hour for diaper change. Seven (7) out of eight (8) residents indicated that toileting and/or incontinence assistance is provided by staff. Regarding the allegation “Staff left resident unattended in soaking wet diaper for extended period,” based on interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.


No deficiency was cited for this allegation.
Allegation(s):

Staff did not report unusual incidents involving resident.


The investigation revealed the following: Regarding the allegation "Staff did not report unusual incidents involving resident,” it is being alleged that staff did not inform R1’s family of the 10/17/22 incident. Record reveals that the facility completed an internal incident report on R1’s injury, contacted R1’s doctor and Power of Attorney (POA) on 10/17/22, left a voicemail with the POA on 10/19/22 2:08 PM, and faxed an incident report to Community Care Licensing on 10/21/22 3:36 PM. Interview with the Administrator indicated that the process for reporting a incident report is to fax the incident report within 2 days, but staff states they make a report within Department of Social Services’ dates. Five (5) out of five (5) staff interviews indicated that incident reports are completed. Regarding the allegation “Staff did not report unusual incidents involving resident,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.


No deficiency was cited for this allegation.

Continue to LIC9099-C

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20221020162028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PARK AT CULVER CITY
FACILITY NUMBER: 198320242
VISIT DATE: 05/28/2024
NARRATIVE
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Allegation(s):
Staff do not provide proper food services to resident.

The investigation revealed the following: Regarding the allegation "Staff do not provide proper food services to resident,” it is being alleged that the food is not edible for Resident #1. Interviews with the Sous Chef, Lead Server, and Caregiver indicated that special diet accommodations are met for residents. Chef and Server also indicated that accommodations are made for residents who needs assistance with cutting their meats. The Chef indicated that meats are left to simmer for softness. The Lead Server assists with orders and indicated that real potatoes opposed to boxed potatoes are used for mash potatoes. Interview with the Administrator indicated that the food is well made, they have no issues regarding the food, the facility provides a weekly meal plan, the facility provides 3 meals per day and snacks, and no resident goes without food. Six (6) out of 7 resident interviews indicated that three meals and snacks are provided by the facility. Regarding the allegation “Staff do not provide proper food services to resident,” based on interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.



No deficiency was cited for this allegation.

Continue to LIC9099-C

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20221020162028
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PARK AT CULVER CITY
FACILITY NUMBER: 198320242
VISIT DATE: 05/28/2024
NARRATIVE
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Allegation(s):
Facility does not have a vehicle to transport wheelchair-bound residents.

The investigation revealed the following: Regarding the allegation "Facility does not have a vehicle to transport wheelchair-bound residents,” it is being alleged that the facility does not have a driver nor a van. Interview with the Administrator indicated that the facility has a van, vehicle, and bus. However, on R1’s finger (10/17/22) incident date, the facility’s driver was sick, had medical issues, and stopped working for the company. The Administrator stated that anyone who drives their vehicle must have a special license and, on that day, they worked around the problem and had a x-ray machine come to the facility the next day. Record reviews reveal that the x-ray was completed on 10/18/22. Five (5) out of five (5) staff interviews indicated that the facility offers transportation. Two of the five staff interviews specifically stated that the facility provides transportation to residents in wheelchairs. Seven (7) out nine (9) residents indicated that they have utilized the facility’s transportation services. Two of the seven (7) residents indicated that they were in a wheelchair. Regarding the allegation “Facility does not have a vehicle to transport wheelchair-bound residents,” based on interviews and record review, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.



No deficiency was cited for this allegation.

An exit interview was conducted and a copy of this report was provided to the Business Office Director Armida Uchiyama.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6