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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320431
Report Date: 11/26/2024
Date Signed: 11/26/2024 12:36:48 PM

Unsubstantiated


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
11/18/2024 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241118102021
FACILITY NAME:IVY PARK AT PALOS VERDESFACILITY NUMBER:
198320431
ADMINISTRATOR:KOUL, KELLEYFACILITY TYPE:
740
ADDRESS:25535 HAWTHORNE BLVD.TELEPHONE:
(310) 377-7425
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:115CENSUS: 69DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Kristal Jenkins-Interim Executive DirectorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff threatened a resident with eviction.
Staff do not properly maintain the facility.
Staff do not provide adequate food service.
INVESTIGATION FINDINGS:
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On 11/26/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Kristal Jenkins/Interim Executive Director. LPA Iniguez explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#6) and Resident’s interviews (R#1-R#6). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#6) Identification and Emergency Information, (R#1-R#6) Admissions agreements, Copies of facility menu (6 weeks) and a Health and safety check of the facility.


Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 5
Control Number 11-AS-20241118102021
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 PALOS VERDES
FACILITY NUMBER: 198320431
VISIT DATE: 11/26/2024
NARRATIVE
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Investigation Revealed the Following:

Allegation: Staff threatened a resident with eviction.

The details of the complaint alleged that administrator threatened a resident with eviction.



During the records review, LPA Iniguez reviewed the Special Incident Report (SRI) or LIC 624 on the completed file. LPA observed that there have been no eviction notices in the past two months.

During an Interview with the Administrator (A#1), she stated that she has never been hostile toward a resident’s family, PO, or representative and has never threatened to evict a resident in care.

During interviews with residents (R#1-R#6), (6) out of (6) stated that they have never been treated with hostility by the facility administrator toward them and their family members, POA, and representatives, and they have never been threatened with eviction.

During interviews with staff (S#1-S#6), (6) out (6) stated that the facility administrator has never been hostile towards the resident’s family, POA, or representatives, and she has never threatened a resident with eviction.

Allegation: Staff do not properly maintain the facility.

The details of the complaint alleged that facility is not properly maintained by staff.




Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20241118102021
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 PALOS VERDES
FACILITY NUMBER: 198320431
VISIT DATE: 11/26/2024
NARRATIVE
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During the records review, LPA Iniguez reviewed the Special Incident Report (SRI) or LIC 624 on the completed file. LPA observed that there have been no eviction notices in the past two months.

During an Interview with the Administrator (A#1), she stated that she has never been hostile toward a resident’s family, PO, or representative and has never threatened to evict a resident in care.

During interviews with residents (R#1-R#6), (6) out of (6) stated that they have never been treated with hostility by the facility administrator toward them and their family members, POA, and representatives, and they have never been threatened with eviction.

During interviews with staff (S#1-S#6), (6) out (6) stated that the facility administrator has never been hostile towards the resident’s family, POA, or representatives, and she has never threatened a resident with eviction.

Allegation: Staff do not properly maintain the facility.

The details of the complaint alleged that facility is not properly maintained by staff.



During a health and safety check of the facility, LPA Iniguez toured all the facility floors and randomly selected (4) residents’ rooms. LPA observed that the facility and resident rooms were clean and sanitary.

During an Interview with the Administrator (A#1), she stated that the facility is clean and sanitary.

During interviews with residents (R#1-R#6), (6) out of (6) stated that the facility is clean and sanitary.

During interviews with staff (S#1-S#6), (6) out (6) stated that the facility is clean and sanitary.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20241118102021
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 PALOS VERDES
FACILITY NUMBER: 198320431
VISIT DATE: 11/26/2024
NARRATIVE
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Allegation: Staff do not provide adequate food service.

The details of the complaint alleged that facility staff do not provide adequate food service to residents in care.



During the records review, LPA Iniguez observed seven weeks of the facility menu. The menu offers a variety of meals throughout the day, such as breakfast, soup of the day, lunch special, lunch side, dinner special, starch, vegetables, and dessert.

During a health and safety check of the facility, LPA observed the kitchen with enough perishable and non-personal food for the residents in care for at least seven days.

During an Interview with the Administrator (A#1), she stated that the facility provides adequate food for residents in care.

During interviews with residents (R#1-R#6), (6) out of (6) stated that the facility provides adequate food for them and the rest of the residents.

During interviews with staff (S#1-S#6), (6) out (6) stated that the facility provides adequate food for the residents in care.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20241118102021
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 PALOS VERDES
FACILITY NUMBER: 198320431
VISIT DATE: 11/26/2024
NARRATIVE
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Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.


An exit interview was conducted, and a copy of the Complaint Report was given to Kristal Jenkins /Interim Executive Director.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5