198320431-7-2-2024-11-AS-WGIS-D6SUPZ-20240702154623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320431
Report Date: 07/02/2024
Date Signed: 07/02/2024 03:46:41 PM

Document Has Been Signed on 07/02/2024 03:46 PM - 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	IVY PARK AT PALOS VERDES		FACILITY NUMBER:	198320431
ADMINISTRATOR:	KOUL, KELLEY		FACILITY TYPE:	740
ADDRESS:	25535 HAWTHORNE BLVD.		TELEPHONE:	(310) 377-7425
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	115	CENSUS: 77	DATE:	07/02/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Kelley Koul		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/02/24, Licensing Program Analysts (LPA), Wendy Gibbs and Perry Scott, conducted an announced pre-licensing visit to the facility listed above. LPAs met with Administrator, Kelley Koul, and the purpose of today’s visit was explained. There were 77 clients at the facility during the time of visit. An application was submitted to CCLD on 10/20/23 for a change of ownership. The facility is a Residential Care Facility for the Elderly serving residents aged 60 and over, of which 107 can be non-ambulatory and 8 can be bedridden. Physical Plant/Structure The facility is a five-story structure located in a commercial neighborhood. The ground floor is the parking and entrance, the first and second floors are Assisted Living, the third floor is Memory Care and the fourth floor is Memory Care. There is a total of 37 Assisted Living units and 61 Memory Care units, each unit contains a bathroom. On the first floor there are 3 common bathrooms, beauty salon, 2 common areas with a TV, computer room, dining room, bistro area, industrial kitchen, storage rooms, laundry room, offices, and staff break room. The second floor consist of an activity room/theater room, bistro, wellness center, laundry room, staff offices, and storage rooms. The third and fourth floor consist of a kitchen, dining room, activity room, TV room, shaded outdoor patio, staff offices, storage room, and laundry room. During the tour, LPA did not observe any bodies of water on the premises. The outside patio/garden area

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT PALOS VERDES	FACILITY NUMBER: 198320431
	VISIT DATE: 07/02/2024

NARRATIVE

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has a shaded area with tables and chairs. The gates exiting the patio are egressed, and work properly. All outside walkways were observed to be clean, clear, and free of obstructions, debris, and hazards. All windows, screens, curtains, and blinds were observed to be in good repair and operate properly.
Rooms LPAs inspected all resident rooms and observed them to be clean and in good repair. LPAs observed the rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. Residents have the option to furnish the rooms how they would like, or the facility has furniture available if residents need it. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Residents do have the option to use their personal linens, or the facility has a supply. LPAs observed an additional supply of linens in a storage room. All linens and mattress were observed in good condition. All rooms were observed to have ample lighting.
Bathrooms LPAs observed all bathrooms to be operable and within Title 22 regulations. The toilet, facets, and shower work properly. The bathrooms were observed clean. The showers were observed with secured safety handrails, nonskid mats, and a shower chair. The showers were observed to be free of mold and mildew. LPA observed storage space for residents’ hygiene products. LPAs observed an ample supply of towels and hygiene products available for residents or residents have the option to supply their own. The water temperature measured between 113.3-degrees and 117.5-degrees Fahrenheit.
Kitchen LPAs observed the industrial kitchen to be clean and sanitary during time of visit. LPAs observed all appliances to be operable and in good repair. LPA

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT PALOS VERDES	FACILITY NUMBER: 198320431
	VISIT DATE: 07/02/2024

NARRATIVE

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observed an ample supply of cookware, dishware, and cutleries. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods were observed properly dated, labeled, packaged, and stored. The freezer temperature measured 0-degrees Fahrenheit, and the refrigerator temperature measured 45-degrees Fahrenheit. LPA observed knives and sharps to be secured and are inaccessible to residents. LPA observed a menu posted in the dining room. The third and fourth floor kitchens were observed to be clean and sanitary. LPA observed a supply of snacks and drinks available for residents at any time LPA observed cleaning supplies and sharps to be secured in a locked storage room and are inaccessible to residents. All trash cans were observed with tight fitting covers.
Common Rooms LPAs observed all common rooms to have ample seating to accommodate residents. LPAs observed all dining rooms to have ample seating to accommodate residents. In the activity room, LPAs observed arts, crafts, games, puzzles, and reading material available for residents. LPAs observed a daily and monthly activity schedule. LPAs observed laundry rooms, that are available to residents, to be clean and in good repair. All walkways, hallways, and stairs in the facility were observed to be clean, clear, and free of hazards and obstructions. The facility was kept at a comfortable temperature of 72-degrees Fahrenheit. All rooms and hallways were observed to have ample lighting.
Files LPAs observed resident files secured in the locked wellness room and are inaccessible to residents. The facility does not handle resident’s finances. The staff files are secured in the business office and are inaccessible to residents.
Safety LPAs tested smoke detectors on each floor and carbon monoxide detectors in each resident unit and found them to be operable. When smoke detectors were

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT PALOS VERDES	FACILITY NUMBER: 198320431
	VISIT DATE: 07/02/2024

NARRATIVE

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triggered, fire doors on each floor operated properly. LPA observed multiple fully charged fire extinguisher last serviced on 05/17/24, throughout the facility. The Fire Safety Inspection was conducted on 05/14/24. The last emergency drill was conducted on 06/28/24. LPAs observed an evacuation chair at each staircase. The facility has a working landline telephone. LPAs observed the facility’s Emergency and Disaster Plan posted. LPAs observed all required posting, posted throughout the facility. LPAs tested the signal system in residents’ rooms and in common bathrooms. LPAs received and reviewed a copy of the liability insurance through Acord.
Medications LPAs observed medications secured in locked medication cart on each floor. Medications are inaccessible to residents. LPAs observed medications to be in their original packaging. LPAs observed a fully stocked First Aid kit with a current manual, in the wellness room. LPAs observed additional First Aid supply secured in a storage room.

LPAs and Administrator reviewed and discussed Component III.

During today's visit, LPA did not observe any issues requiring corrections.

LPAs will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

An exit interview was conducted with Administrator, Kelley Koul, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

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