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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320242
Report Date: 05/10/2023
Date Signed: 05/11/2023 08:19:34 AM


Document Has Been Signed on 05/11/2023 08:19 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



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: 81DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator- Brinttney BuchannanTIME COMPLETED:
02:30 PM
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On 05/10/23 Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Administrator Brittney Buchanan and as the purpose of today’s visit was explained. The facility is licensed to operate 150 non-ambulatory residents of which 10 maybe bedridden ages 60 and over. The facility has an approved Hospice Waiver for 15 residents.

The facility is a large three-story building located in a residential neighborhood. 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 conducted record reviews of eight (8) residents records, five (5) staff records and eight (8) Client Medication Administration Records. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked.

LPA checked resident units, mattresses and box springs were in good condition, adequate lighting and plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to residents. The water temperatures measured between 105 F.- 120 F.

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector and smoke detectors were observed, fire extinguishers were fully charged, toxins and .

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: IVY PARK AT CULVER CITY
FACILITY NUMBER: 198320242
VISIT DATE: 05/10/2023
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knifes were locked and inaccessible to residents. The facilities the last drill was conducted on 04/30/23. The facility disaster plan is current and in compliance with Title 22 regulations at the time of visit.

Exits/ Walkways around the facility were free of debris and hazards.

During today’s visit no deficiencies were observed. Exit interview conducted with

Administrator Brittney Buchannan and a copy of this report was provided

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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