198320242-4-18-2023-11-AS-UCOL-CSCNU2-20230531104535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320242
Report Date: 04/18/2023
Date Signed: 04/18/2023 04:20:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2023 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230413141046

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: 79	DATE:	04/18/2023
		UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Brittany Buchannan - Executive Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not provide responsible party with a complete admissions agreement.
Staff is charging resident fees for services not rendered.

INVESTIGATION FINDINGS:

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On 04/18/2023 Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Mario Leon conducted an initial complaint investigation for the allegations listed above. LPM and LPA was assisted by Health Services Director Amber Reynolds and Executive Director Brittany Buchannan. LPM and LPA explained the purpose of today's visit is to investigate the allegations listed above.

The investigation consisted of the following:
A tour of the facility was conducted. A review of the facility and resident records were conducted. Interviews with the administrator, facility nurse, caregiver and three residents were conducted.

The investigation revealed the following:
Regarding the allegation, "Staff did not provide responsible party with a complete admissions agreement.", it is alleged that residents responsible persons did not receive a complete admissions agreement upon admission. (Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230413141046

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/18/2023

NARRATIVE

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A review of residents Admission Agreements indicate that said documents were received by the residents' and responsible persons. Interviews with staff revealed that the residents and their responsible persons received copies of the Admissions Agreement upon admission. During the investigation 3 out of 3 residents interviewed did not have any issues obtaining copies of their records. Regarding the allegation, "Staff did not provide responsible party with a complete admissions agreement." Based on Interviews and record reviews conducted there is insufficient evidence to support the allegation mentioned above. 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 is Unsubstantiated.

Regarding the allegation, "Staff is charging resident fees for services not rendered" A review of residents Admission Agreements, Resident Assessments, Physicians Reports and Fee Ledgers indicate that fees charged for services are based on the Physicians Reports, Facility Nurse Assessments and the "Change of Service Plan and Fees for Additional Items and Services, Care Points and Levels of Care" of the Admission Agreements. Regarding the allegation, "Staff is charging resident fees for services not rendered" Based on Interviews and record reviews conducted there is insufficient evidence to support the allegation mentioned above. 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 is Unsubstantiated.

There were no deficiencies cited today. A copy of this report was provided to Amber Reynolds.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC9099 (FAS) - (06/04)

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