198320242-6-15-2024-11-AS-AINZ-D69TSQ-20240615145931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320242
Report Date: 06/15/2024
Date Signed: 06/15/2024 02:59:42 PM

Document Has Been Signed on 06/15/2024 02:59 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	IVY PARK AT CULVER CITY		FACILITY NUMBER:	198320242
ADMINISTRATOR:	BRITTNEY BUCHANNAN		FACILITY TYPE:	740
ADDRESS:	4061 GRAND VIEW BLVD.		TELEPHONE:	(949) 744-5200
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY:	150	CENSUS: 81	DATE:	06/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Armida Uchiyama-Business Director		TIME COMPLETED:	03:00 PM

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On 6/15/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Armida Uchiyama/Business Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (150) elderly adults ages 60 and above, of which (150) can be non-ambulatory and (10) Bedridden. The facility has an approved hospice waiver for (15).

The facility has a memory care unit and an assisted living unit; the assisted living unit consist of three units which includes resident rooms, common area, kitchen, dining area, an outdoor shaded area, a laundry room, reception area and administrative offices. Memory care unit consist of resident rooms, dining area, common area, delayed egress doors. The facility has a signal system with the switch board in the reception area and is operational from all resident living units.

LPA Iniguez and the Businnes Oficce Director toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (10) bedrooms and (10) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 117°F to 118.°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: IVY PARK AT CULVER CITY	FACILITY NUMBER: 198320242
	VISIT DATE: 06/15/2024

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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 5/10/24.

A review of (5) residents' service files and (5) staff personnel files was maintained in order. LPA reviewed (5) Medication Administration Records (MARs) no discrepancies were found by LPA.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA. Facility Annual Fess current.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies; therefore, no citations were issued at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Armida Uchiyama/Business Office Director.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

LIC809 (FAS) - (06/04)

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