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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320242
Report Date: 12/14/2023
Date Signed: 12/15/2023 09:03:44 AM


Document Has Been Signed on 12/15/2023 09:03 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:
12/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Armida UchiyamaTIME COMPLETED:
12:22 PM
NARRATIVE
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On 12/14/2023 at 8:11 am Licensing Program Analyst (LPA) David España conducted an initiated a 10-day complaint investigation visit for the allegation listed and developed a case management-other. Upon arriving at the facility, LPA met with S#1 who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection.

LPA was granted access and allowed to enter the facility to conduct inspections. The care management consisted of the following: On 12/14/2023 at 8:11 am LPA España conducted a tour of facility plant with S#1; and requested to review records of Six (6) out of Eighty-One (81) residents in care records. LPA toured the outside and indoor memory care unit with S#1 and with S#3. LPA met on tour Seven (7) out of Twenty-Five (25) staff members at the time of visit on 12/14/2023.

During the course of the visit LPAs smelled gas in a storage shed by memory care unit entrance door next to the outdoor green generator in front of the memory care unit. According to maintenance staff the gas company customer service agent was called, and the regional office has been informed. LPA requested for records of services from the maintenance staff maintenance records: LPA requested records of (1) Generator maintenance (log for the past three months); (2) A/C maintenance (log for the past three months); (3) Gas company maintenance (log for the past three months); (4) Facility maintenance of lighting of both floors and back area (log for the past three months); (5) Records of maintenance of toilets, bathtub, sink, washer, dryer, kitchen, parking lot, facility lights, facility vents, gas, A/C, and other (log for the past three months); (6) Records of maintenance of A/C if any (log for the past three months) and (7) a written narrative stating the amount of months gas leak has been on going at the facility as of 12/14/2023. Continued on LIC 809-D.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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Document Has Been Signed on 12/15/2023 09:03 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2024
Section Cited
CCR
87303(f)(1-2)

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87303(f)(1-2) Maintenance and Operation
(f)Solid waste shall be stored and disposed of as follows: (1)Solid waste shall be stored, located and disposed of in a manner that will not permit the....municable disease or of odors, create a nuisance.... or rodents. (2)Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.
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Licensee will fix trash bins in outdoor sector of the facility in front of memory care unit. Licensee will email proof of correction to David.espana@dss.ca.gov.
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Based on observation, and interview, the licensee did not comply with the section cited above in, lose or uncovered trash bins not working properly (flies, insects, and mosquitoes observed), which poses a potential health, safety or personal rights risk to persons in care.
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Type B
01/14/2024
Section Cited
CCR87303(a-e)

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87303 (a-e) Maintenance and Operation
(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of..., employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition…(c) All window screens shall be clean and maintained in good repair. (d)There shall be lamps or light appropriate for the use of each... comfort and safety of all persons in the facility. (e)Water supplies and plumbing fixtures shall be maintained as follows: (1)All community care facilities where water for human consumption is from a private…
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Based on observation, and interview, the licensee did not comply with the section cited above in, screens in despair and gas leak, which poses a potential health, safety or personal rights risk to persons in care
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Licensee will gas leak and trash bins in outdoor sector of the facility in front of memory care unit. Licensee will email proof of correction to David.espana@dss.ca.gov.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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: 12/14/2023
NARRATIVE
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Based on LPAs observations, the gas company did not service the gas valves and a large amount of gas smells have been observed by S#4. The maintenance staff stated they will send the gas company report to CCL today 12/14/2023. LPA with S#1 observed the facility window screens, and hinges, needing of repairing on thel back side of the facility. LPA noted damaged screens in the courtyard and the front of the facility. LPA noted memory care unit screen material to be dated and in need of repair 8 plus screens observed. This poses a risk to residents in care. LPA noted trash bins open with disposal or solid trash and other.

The following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87303 (a-e) Maintenance and Operation and Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87303(f)(1-2) Maintenance and Operation on the LIC 809D.

An exit interview was conducted at 1:10 PM, and a hard copy with appeal rights was provided to S#1.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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