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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320242
Report Date: 10/14/2025
Date Signed: 10/14/2025 12:57:06 PM

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
08/13/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20240813161052
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: 79DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Executive Director, Tierre ThorntonTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Due to staff neglect, resident was covered in ants
Staff are not adequately trained in an emergency
Staff wiped resident's body down with chemicals
Lack of care and supervision
INVESTIGATION FINDINGS:
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*This report serves as an amendment to clarify findings. It supersedes the complaint investigation findings reflected on report created 10/6/25.

On 10/7/2025, Licensing Program Analyst (LPA) Felisa Shirley conducted a subsequent visit to conduct a complaint investigation and deliver investigation findings at this facility. Upon arrival, LPA met with Business Office Manager, Armida Uchiyama who assisted with the visit. LPA explained the purpose of today's visit and was granted entrance to facility grounds.

The investigation consisted of the following: On 8/15/24 LPA Jose Calderon requested Incident Report for 08/12/2024, CPR training for staff, Pest control reports for past 3 months, hospice records, physician report, needs and service plan, fire department paperwork, and DNR paperwork. On 11/14/24 LPA Felisa Shirley requested documentation and Interviewed 4 staff members. On 11/22/24, LPA Felisa Shirley and LPM Stephanie Cifuentes requested Staff and Resident rosters, facility records for R1, hospice records, Death Certificate, Special Incident Reports for 8/10/24 to 8/15/24. The Department conducted interviews with Staff 1 to staff 8(S1-S8), Witness 1 and Witness 2 (W1 and W2). LPA Felisa Shirley conducted (7) staff interviews, Staff 9 – Staff 15, (S9 – S15) and (7) resident interviews, Resident 2 – Resident 8, (R2 – R8). R1 could not be interviewed as they passed away on 8/12/24.
Con’d on 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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 11
Control Number 11-AS-20240813161052
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: 10/14/2025
NARRATIVE
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Investigation revealed the following:

Allegation: Due to staff neglect resident was covered in ants

It is being reported that R1 was found covered in ants during her demise due to staff neglect. LPA Shirley reviewed Culver City Fire Departments report dated 8/12/24. Per the report, when paramedics entered the room to conduct assessment of R1, they found that R1 was covered in ants. The department interviewed Witness 1 (W1) who stated that on 8/12/24, W1 arrived at the facility and observed S1 spraying R1 with Lysol because, as he was told by S1, her body was infested with ants. W1 also observed ants on R1. The department interviewed witness 2 (W2), who stated that when they arrived at facility, R1’s body was covered in ants. The department reviewed pest control service reports from Eco Lab Pest Control, service date 8/13/24. Per the service reports, multiple ant colonies were observed during treatment of the exterior areas. Per interview with facility Regional Operations Specialist, the facility was also serviced on 6/24/24, 7/8/24 and 7/18/24.
Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.


Con'd on 9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 11
Control Number 11-AS-20240813161052
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: 10/14/2025
NARRATIVE
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Allegation: Staff are not adequately trained in an emergency

It is being alleged that staff are not properly trained to assist in an emergency. LPA interviewed staff 9 – staff 15 (S9 – S15). Of those interviewed, 4 denied the allegation and 3 agreed. LPA interviewed resident 2 – resident 8 (R2 – R8). Of those interviewed 3 denied the allegation, 2 confirmed the allegation and 2 were not sure.
The department interviewed witness 1(W1). Per interview with W1, on 8/12/24, facility staff could not find residents paperwork when the fire department arrived. On 4/30/25, the Department reviewed facility files. Observation of S8’s Disciplinary Action Notice, dated 9/12/24 shows that there were concerns with a lack of staff training, in particular staff trained on Safety/Care protocols. During a further review of the Disciplinary Action Notice, emergency personnel were concerned about the inability of staff to answer basic questions regarding R1. Emergency personnel reported that several functions of S8’s job duties were not in line with Oakmont Management Group, OMG policy and standard.
Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

Con'd on 9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 11
Control Number 11-AS-20240813161052
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: 10/14/2025
NARRATIVE
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Allegation: Staff wiped resident’s body down with chemicals

It is being alleged that facility staff were observed wiping down a resident’s body with Lysol. The department reviewed records and observed that according to the Culver City Fire Department report dated 8/12/25, paramedics arrived at facility and observed S1 spraying R1 with Lysol. The department interviewed Witness 1 (W1) who stated that on 8/12/24, W1 arrived at the facility and observed S1 spraying R1 with Lysol because, as he was told by S1, her body was infested with ants. The department reviewed Lysol use, and per Lysol website: “Lysol disinfecting and cleaning products are for surfaces and not for personal use. They cannot be used on the body or on food and always should be used as directed.” On 10/6/2025 LPA Shirley interviewed staff 9 – staff 15 (S-9 – S-15). Of those interviewed 7 out of 7 denied the allegation. On 10/6/2025 LPA Shirley interviewed resident 2 – resident 8 (R2 – R8). Of those who interviewed, 7 out of 7 denied the allegation.
Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

Con'd on 9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 11
Control Number 11-AS-20240813161052
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: 10/14/2025
NARRATIVE
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Allegation: Lack of care and supervision

It is being alleged that facility staff did not follow residents plan of care, which could have contributed to R1’s death. On 10/3/2025 LPA Shirley reviewed facility records, according to the records, R1 entered Ivy Park of Culver City on January 8, 2024. R1’s Physicians assessment, dated 1/24/24, states that R1 needed assistance eating. On 10/3/2025 LPA Shirley reviewed Hospice records from AA Family Hospice Care, Inc. for R1, according to the hospice plan of care dated 2/7/2024 R1 needed assistance with her meals, as she was known to pocket food and was on a mechanical soft diet. AA Family Hospice Care, Inc hospice notes, dated 7/17/24, noted that the facility followed aspiration precautions and that as the patient was noted to be pocketing food, the facility performed oral care after each meal. LPA Shirley reviewed the facility menu dated 8/11/24 and observed that beef and broccoli was served that evening.

The Department interviewed Staff 1-Staff 7(S1-S7) and out of those interviewed, three (3) staff stated they did not assist R1 with eating that day and that they did not know who did. The Department interviewed Staff 1-Staff 7(S1-S7) and out of those interviewed, zero (0) stated that they had checked on R1 after she was put to bed on 8/11/2024.

Con'd on 9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 11
Control Number 11-AS-20240813161052
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: 10/14/2025
NARRATIVE
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LPA Shirley reviewed Culver City Fire Departments report dated 8/12/25. Per report, facility staff told Culver City Fire department staff that it had been three to five hours since they had seen R1. The department interviewed Witness 2 (W2) who admitted to failing to document her findings in her death visit report. W2 further stated that they found what looked like vomit with thick pieces and strains of meat in R1’s mouth, which was not normal.

Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.

Deficiencies were cited during today's visit.

An exit interview was conducted, and plans of corrections were developed with the Executive Director, Tierre Thornton. A copy of this report and appeals rights were provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 11
Control Number 11-AS-20240813161052
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: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2025
Section Cited
CCR
87468.2
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
This requirement was not met, as evidenced by:
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The Administrator shall review Title 22 section 87468.2 and provide in-service training to staff on resident’s personal rights in life and death. Copy of training sign in sheet and written statement acknowledging understanding of Title 22 87468.2 shall be submitted to the department by the POC due date via email to felisa.shirley@dss.ca.gov or fax to 424-544-1016.
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Based on records reviewed and interviews, on 8/12/2024, Resident1’s (R1’s) body was found covered in ants. This poses an immediate health, safety and personal rights risk to people in care.
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Deficiency Dismissed
Type B
10/21/2025
Section Cited
CCR
87411(a)
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 Staff are not adequately trained in an emergency

87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement was not met:
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The Administrator shall review Title 22 and provide copies of In-Service trainings on mandatory preparedness for all staff. Please forward a copy of trainings by the POC due date 10/21/ emergency 25. Proof of correction will be emailed to felisa.shirley@dss.ca.gov or fax to 424-544-1016. *POC rec’d 10/8/25 Medical Emergencies – Calling 911
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Based on records reviewed and interviews, on 8/12/24, facility staff were unable to provide emergency services staff with basic information and documentation for R1 which poses a potential health risk to residents in care.
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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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 11
Control Number 11-AS-20240813161052
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: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/08/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:

(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met:

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The facility will conduct In-Service trainings for post mortem procedures and will provide copies of the sign-in sheets to CCLD by POC due date. Please forward a copy of trainings by the POC due date. Proof of correction will be emailed to felisa.shirley@dss.ca.gov or fax to 424-544-1016. *POC cleared prior to visit, rec’d 10/8/25.
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Based on records reviewed and interviews on 8/12/24 S1 wiped R1’s body with Lysol, which poses an immediate health risk to residents in care.
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Deficiency Dismissed
Type A
10/08/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement was not met:
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The facility will conduct In-Service trainings on reviewing and following Appraisals/Needs and Services plans and the importance of checking on residents throughout the evening. Please forward a copy of trainings to CCLD by the POC due date. Proof of correction will be emailed to felisa.shirley@dss.ca.gov or fax to 424-544-1016. *POC cleared prior to visit, rec’d 10/8/25.

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Based on records reviewed and interviews, on 8/12/24 facility staff did not monitor R1’s meals, which poses an Immediate health risk to residents in care.
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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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 11
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
08/13/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20240813161052

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: 79DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Executive Director, Tierre ThorntonTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not perform CPR timely
Questionable death
INVESTIGATION FINDINGS:
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On 10/7/2025, Licensing Program Analyst (LPA) Felisa Shirley conducted a subsequent visit to conduct a complaint investigation and deliver investigation findings at this facility. Upon arrival, LPA met with Business Office Manager, Armida Uchiyama who assisted with the visit. LPA explained the purpose of today's visit and was granted entrance to facility grounds.

The investigation consisted of the following: On 8/15/24 LPA Jose Calderon came and requested documentation. On 11/14/24 LPA Felisa Shirley came to request documentation and Interviewed 4 staff members. On 11/22/24, LPA Felisa Shirley and LPM Stephanie Cifuentes arrived at this facility and requested Staff and Resident rosters, facility records for R1, hospice records, Death Certificate, Special Incident Reports for 8/10/24 to 8/15/24. The Department conducted ten (10), interviews and LPA Felisa Shirley conducted (7) staff interviews, Staff 9 – Staff 15, (S9 – S15) and (7) resident interviews, Resident 2 – Resident 8, (R-2 – R-8). R1 passed away 8/12/24.

Investigation revealed the following:
Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 9 of 11
Control Number 11-AS-20240813161052
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: 10/14/2025
NARRATIVE
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Allegation: Staff did not perform CPR timely

It was reported that staff did not perform Cardiopulmonary Resuscitation, (CPR) on R1. The department reviewed records, and found that per Ivy Park CPR policy in R1’s Resident Service Agreement, staff are trained and on duty 24 hours a day who can administer CPR. If you indicate that you wish to have CPR performed, staff will initiate CPR until emergency medical personnel arrive. If you indicate that you do not wish to have CPR, we will honor your wish by not initiating CPR and informing emergency medical personnel of your decision. LPA Shirley reviewed facility records and found signed Physician Orders for Life-Sustaining Treatment (POLST) dated 7/3/24 stating Do Not Attempt Resuscitation, (DNR) for R1. Per Culver City Fire Department report dated 8/12/24, CPR was declined by facility and Emergency Medical Dispatch (EMD) was refused. The department interviewed Witness 1 (W1). Per W1, the staff withheld doing CPR because it was beyond help and would not help R1.

LPA interviewed staff 9 – staff 18 (S-9 – S-15). Of those interviewed 6 out of 7 denied the allegation and knows how to and when to perform CPR. 1 staff does not know CPR. Of those interviewed, 3 staff knew protocol if there is a DNR in place and 4 did not.

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; therefore, the allegation of “Staff did not perform CPR timely,” is found to be unsubstantiated.


Allegation: Questionable death

It is being alleged that R1 died at this facility under suspicious circumstances. The Department reviewed death certificate for R1, and The Department observed cause of death to be Cardiopulmonary Arrest and Alzheimer’s listed as cause of death. The department requested a coroner’s reports, but no autopsy was conducted. LPA Shirley reviewed Culver City Fire Departments report dated 8/12/25, per report paramedics arrived at facility

con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 10 of 11
Control Number 11-AS-20240813161052
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: 10/14/2025
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at 1:20am and found resident 1 (R1) pulseless and cold with fixed and dilated pupils. Facility staff provided paramedics with Physician Orders for Life-Sustaining Treatment (POLST) stating Do Not Attempt Resuscitation. Per review of R1’s Physician’s Report, dated 2/7/24, R1 was diagnosed with Alzheimer disease, HTN, Seizures, HLP, insomnia and depression. Per review of AA Family Hospice Care, Inc. Patient Consent for Care and Service Agreement, R1 began receiving hospice services 7/3/24, having been advised by her physician of her diagnosis and prognosis.

LPA interviewed staff 9 – staff 15 (S-9 – S-15). Of those interviewed, 2 out of 7 denied the allegaton, 2 were not working at the facility at that time, 1 did not know and 2 were not available.

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; therefore, the allegation of “Questionable Death,” is found to be unsubstantiated.



No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Executive Director, Tierre Thornton.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 11 of 11