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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320242
Report Date: 07/25/2024
Date Signed: 07/25/2024 04:26:07 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, 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
07/18/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240718150621
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:
07/25/2024
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Armida Uchiyama, Business Office DirectorTIME COMPLETED:
04:47 PM
ALLEGATION(S):
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Staff do not ensure the facility is kept free of mal odors
Staff do not ensure residents beds are in good repair
Staff do not ensure old food is being properly discarded
“Staff do not ensure facility is kept free of insects
Staff do not ensure infection control guidelines are being followed
Staff do not ensure residents are provided with fresh clean linens
INVESTIGATION FINDINGS:
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On 07/25/24 Licensing Program Analyst's (LPAs) Mario Leon and Jose Calderon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA's were met by Armida Uchiyama, Business Office Director (S2) and the purpose of the visit was explained. S2 and LPAs toured the facility.
The investigation consisted of the following:
On 07/25/24 LPA's requested and reviewed facility documents, such as follows: staff and resident rosters, facility insect control documentation between the dates of 05/30/2024 through 07/18/2024, Housekeeping and laundry schedule(s), physician's report for resident one (R1) along with R1's face sheet and LPA's toured the facility. LPA's interviewed eight (8) out of eighty-three (83) residents (R2-R9) and staff one, two, and three (S1-S3).
The investigation revealed the following:
Regarding the allegation, “Staff do not ensure the facility is kept free of mal odors.”, it has been alleged that the memory care unit of the facility has a foul smell of urine and feces due to residents being left in their soiled clothing for extended periods of time. Report continues, see LIC9099C.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
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 4
Control Number 11-AS-20240718150621
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: 07/25/2024
NARRATIVE
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Interviews revealed that all three (3) staff and all eight (8) residents have denied that the allegation has taken place. All eight residents have verified there is no malodorous scent throughout the facility. LPA's Leon and Calderon toured the facility and did not observe or detect any malodorous scents in both the AL and MC wing unit.

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation, “Staff do not ensure residents beds are in good repair.”, it has been alleged that residents have broken their hospital beds, which have not been replaced, which has resulted in staff not being able to lift residents from their beds to assist residents and change the residents’ clothing.


Interviews revealed that all three (3) staff and all eight (8) residents have denied that the allegation has taken place.

LPA's Leon and Calderon toured the facility and inspected five (5) beds in the MC wing, which included room numbers as follows: two (2), three (3), seven (7), nine (9) and eleven (11) and were denied entry to room (13).

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation, “Staff do not ensure old food is being properly discarded.”, it has been alleged that old left over food is being left in the fridge located in the memory care unit for a long time instead of being thrown out.


Interviews revealed that all three (3) staff and all eight (8) residents have denied that the allegation has taken place.
LPA's Leon and Calderon observed the large refrigerator, located in the dining room within the MC wing, and did not observe or detect old or moldy food(s). LPA's also observed all small refrigerators in kitchen area and in the AL dining room area and did not observe or detect old or moldy food(s).
Based on LPA's observations and interviews conducted, the preponderance of evidence standard has not been met. Report continues, see LIC9099C.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240718150621
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: 07/25/2024
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation, “Staff do not ensure facility is kept free of insects.”, it has been alleged that the facility has a problem with ants and roaches in the residents’ rooms.
Interviews revealed that all three (3) staff and all eight (8) residents have denied that the allegation has taken place. Record reviews revealed that the facility continues to have pest services done by ECOLAB, and that staff one, Delroy Grant – Maintenance Director (S1) has discarded one rodent that had been caught on Sunday, 07/21/2024, after a door to the central patio area was left open in the MC wing. LPA's did not observe, or detect, any insect remnants nor any rodent remnants in five (5) rooms that were inspected. LPA's searched for rodent remnants throughout the kitchen and did not detect any insect or rodent remnants.
Based on LPA's observations, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation, “Staff do not ensure infection control guidelines are being followed.”, it has been alleged that one of the residents on the assisted living side has an infection called MRSA and the staff let the resident roam around the facility and do not follow any infection control guidelines with isolation and use of personal protective equipment (PPE).

Interviews revealed that all three (3) staff and all eight (8) residents have denied that the allegation has taken place. One staff had confirmed there was Covid in the facility, but that the infected staff was tested positive and was requested to depart from the facility. According to one staff, the facility had one (1) case of Covid-19, but has not been declared an outbreak by the Los Angeles Department of Public Health. Furthermore, one resident (R1) has departed from the facility due to personal issues and is currently staying at the hospital. Internal incident reports were not provided to LPA Leon. Record reviews revealed that the facility does have the Emergency and Disaster Plan for Residential Care facilities for the Elderly (LIC610E), as mandated, on file.

Report continues, see LIC9099C.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20240718150621
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: 07/25/2024
NARRATIVE
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Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation, “Staff do not ensure residents are provided with fresh clean linens.”, it has been alleged that not all the residents are being changed out of their soiled clothing in a timely manner and as a result the residents are soaking through their incontinence supplies and into their linens, which are not being replaced.

Interviews revealed that all three (3) staff and all eight (8) residents have denied that the allegation has taken place. One staff has confirmed that, during their AM shift, they do make rounds to all rooms to verify that all rooms have laundered all residents' clothing appropriately during the PM shift the day before.


Record reviews revealed that the facility does have a weekly laundry schedule for both AL and the WC wing, though the schedules are missing any logged notation from staff.
LPA's Leon and Calderon observed five (5) rooms and did not detect any resident being left in soiled clothing or bedding.

Based on LPA's observations, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

There have been zero (0) deficiencies cited during today's visit.

An exit interview was held with Armida Uchiyama, Business Office Director (S2), and a copy of this report has been provided.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4