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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320242
Report Date: 02/19/2025
Date Signed: 03/10/2025 10:24:06 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2024 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20240806154717
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: 83DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:ADMINISTRATOR TIERRE THORNTONTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff do not respond to call buttons in a timely manner
Licensee does not ensure the facility has an active Director on site
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This report supersedes the report dated 08/15/2024. The investigation findings of 2 out of 4 allegations have changed from Unsubstantiated to Substantiated. The regulation cited for allegation 2 has been updated from 80072(a)(2) to 87468.1(a)(2).
Community Care Licensing Division (CCLD) conducted an unannounced visit to Ivy Park at Culver City facility on 10/02/2024 and met with Manager Armida Uchiyama (S1). CCLD staff explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
During this investigation, CCLD staff interviewed staff S1-S5 and interview residents R1- R8. CCLD staff obtained and reviewed the following records: Physician Report (dated 02/07/2022), Individual Service Plan (ISP) (dated 06/20/2024), Admission agreement (dated 10/01/2021), Physician Orders (dated 04/05/2021), Call log report (dated July-August 2024), Meal Plan (dated 7/7/2024 to 09/28/2024), LIC500 Personnel Report (dated 08/24/2024) for R1.
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
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 5
Control Number 11-AS-20240806154717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: IVY PARK AT CULVER CITY
FACILITY NUMBER: 198320242
VISIT DATE: 02/19/2025
NARRATIVE
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7
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Regarding Allegation: Facility staff do not respond to call buttons in a timely manner.

This complaint alleged that staff did not respond to R1 pushing the call button in a timely manner. During the investigation CCLD staff toured the facility and noted no resident pressing the call buttons. Record review indicate the following: Reviewed call button logs (date July – August 2024), the wait time was between 3 minutes to 38 minutes. Two resident calls were not answered by staff on 07/29/2024 and 08/24/2024. Interviews indicated the following: 2 out of 8 residents indicated that staff did not respond to call button service.

Regarding Allegation: Licensee does not ensure the facility has an active administrator on site.

This complaint alleged that the administrator is only at the facility one day a week. CCLD staff toured the facility on 8/15/2024 and on 10/02/2024 and did not observe a certified administrator working at the facility. Record review indicate the following: Per the staff roster LIC500 (dated 05/25/2024 to 08/24/2024) indicate that the administrator is schedule to work Monday to Friday from 9 am to 5pm. Staff records indicate that no other staff had administrator certificate from May to August 2024. Interviews indicate the following: Administrator S1 indicates that S1 stop reporting to the facility as of May 2024. 2 out of 8 residents indicate that there is no administrator working in the facility.

Based on records review observations and interviews, the preponderance of evidence standard has been met; therefore, the allegation of “facility staff do not respond to call buttons in a timely manner’, and “licensee does not ensure the facility has an active administrator on site” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted, and plans of corrections were developed. A copy of the Complaint Report and appeal rights were provided to the Manager Armida Uchiyama S1.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 11-AS-20240806154717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: IVY PARK AT CULVER CITY
FACILITY NUMBER: 198320242
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2025
Section Cited
CCR
87468.1(a)(2)
1
2
3
4
5
6
7
ersonal Rights of Residents in All Facilities.Residents in all residential care facilities for...To be accorded dignity... To be accorded safe... accommodations furnishings and equipment.
… This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to conduct staff training regarding call button request from residents. Proof of correction must be emailed to LPA Calderon by 03/05/2025.
8
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14
Based on records review and interviews conducted. Facility did not respond to call button being pressed by residents on 7/29/2024 and 08/24/2024. This is a potential health and safety risk to residents in care.
8
9
10
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14
Deficiency Dismissed
Type B
03/05/2025
Section Cited
CCR
87405(a)
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5
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7
Administrator qualifications and duties
All facilities shall have a qualified and currently certified administrator…The administrator shall have sufficient freedom from other responsibilities and shall be on the premises…This requirement was not met as evidence by:
1
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5
6
7
Licensee shall create a plan to have an administrator working at the facility 5 days a week. Proof of correction must be emailed to LPA Calderon by 03/05/2025.
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Based on observations and interviews conducted the facility did not have an active administrator 5 days a week. This is a potential safety risk to residents in care.
8
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14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2024 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20240806154717

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: 83DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:ADMINISTRATOR TIERRE THORNTONTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff does not serve nutritious meals.
Resident's barking dog is interfering with daily living of other residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This report supersedes the report dated 08/15/2024. This complaint investigation findings have stayed the same as Unsubstantiated.
Community Care Licensing Division (CCLD) conducted an unannounced visit to Ivy Park at Culver City facility on 10/02/2024 and was greeted by Manager Armida Uchiyama (S1). CCLD staff explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
During this investigation, CCLD staff interviewed staff S1-S5 and interview residents R1- R8. CCLD staff obtained and reviewed the following records: Physician Report (dated 02/07/2022), Individual Service Plan (ISP) (dated 06/20/2024), Admission agreement (date 10/01/2021), Physician Orders (date 04/05/2021), Call log report (date July-August 2024), Meal Plan (7/7/2024 to 09/28/2024), LIC500 Personnel Report (date 08/24/2024) for R1.
The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20240806154717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: IVY PARK AT CULVER CITY
FACILITY NUMBER: 198320242
VISIT DATE: 02/19/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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Regarding Allegation: Facility staff does not serve nutritious meals.

This complaint alleged food could not be chewed, and rice and pasta are served repeatedly CCLD staff toured the facility to include the dining room around lunch time. Records review indicate: CCLD staff noted a daily menu on the tables and noted the facility kitchen had the 7 day and 2-day food supply on hand. Food served week of 7/7/24 to 7/13/2024 was breakfast items, various soups, chicken tacos, beef chill and fish items, and menu changes from week to week. Interviews indicate the following: 5 out of 5 staff indicate that the kitchen staff serve nutritious meals to residents. 6 out of 8 residents indicate that the food could be better, but the food served by staff are nutritious and taste fine.

Regarding Allegation: Residents barking dog is interfering with daily living of other residents.

This complaint alleged that R3 dog barks and interferes with other residents daily living. CCLD staff toured the facility to include common areas and R3 room. Record review indicate the following. Reviewed the admission agreement for the facility, page 10, section G 2 (pets), pets are allowed. Reviewed facility plans of operations page 6 “pet care” and resident handbook page 7 “pets”, are allowed by the facility. CCLD staff visited R3 room and noted small dog in a cage. Dog was not barking or making a sound. Knocked on R1 room door and noted there was no issue with dog barking. CCLD staff knocked on residents’ doors no one was home. Interviews indicate the following: 5 out of 5 staff indicate that the small dog does bark, but no resident has complained except R1. 6 out of 8 residents have no issues with R3 dog or R3 dog barking.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “facility staff does not serve nutritious meals”, “residents barking dog is interfering with daily living of other residents”, is found to be UNSUBSTANTIATED.

No deficiencies cited during today's visit. An exit interview was conducted and copy of the Complaint Report were provided to the Manager Armida Uchiyama (S1)

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5