198320431-12-3-2024-11-AS-RORN-DBNM7Z-20241205082220

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320431
Report Date: 12/03/2024
Date Signed: 12/03/2024 10:22:06 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
11/13/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20241113145950

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: 69	DATE:	12/03/2024
		UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Kathleen Olson		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility did not refund preadmission fees.
Facility did not provide copies of admission agreement.

INVESTIGATION FINDINGS:

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On 12/03/2024, the department conducted a subsequent unannounced complaint visit to the facility listed above. LPA met with Regional Operations Specialist, Kathleen Olson, and the purpose of today’s visit was explained.

During a previous visit conducted on 11/21/24, the department toured the facility, interview Staff S1-S5, interviewed Residents R2-R8, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Resident Admission Agreement, Resident Billing Statement, Physician orders, Physician’s Report, Healthcare Provider Communication, MC Assessment and Service Plan, Hospice IDG Comprehensive Assessment and Plan of Care Report, and emails between R1’ family and the facility staff.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

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 4

Control Number 11-AS-20241113145950

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/03/2024

NARRATIVE

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to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegations: Facility did not provide copies of admission agreement.

The complaint allegation alleges the family of R1 requested a copy of the admission agreement and despite the request they did not receive a copy.

During record review, the department received and reviewed a copy of R1’s admission agreement.

During interviews with Staff S1-S5, were asked if a responsible party asks for a copy of their residents Admission Agreement how long the process takes them to receive it, five (5) out of five (5) stated once it is confirmed the responsible party has the authority to receive documents it will be provided as soon as possible. Additionally, during interviews with Staff S1-S5, was asked if a copy of the admission agreement is provided to the resident or family once signed, five (5) out of five (5) stated they are provided with a copy at the time of signing.
During interviews with Residents R2-R8, were asked if they received their admission agreement after signing, seven (7) out of seven (7) stated they received a copy of their Admission Agreement before moving in. Additionally, during interview with Residents R2-R8, were asked if they or their family have requested copies of documents from the facility and did not receive them, seven (7) out of seven (7) stated they had no issues or problems getting a copy of documents requested.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20241113145950

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/03/2024

NARRATIVE

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Allegation: Facility did not refund preadmission fees.
The complaint allegation alleges resident R1 moved out of the facility due to staff being unable to provide proper care for them and they were not refunded a percentage of their preadmission fees for not being there a full 90-days.

During record review, the department received and reviewed a copy of R1’s Admission Agreement that states on page 8, section E. Termination, 1. Termination by Resident, that states “If You move out without providing thirty (30) days’ notice, You will be responsible for the amount of you Monthly Fee through the date You move plus one full month’s fees.” Additionally, in the Admission Agreement on page 6, section B. Fees, 1. Community Fee, states “The length of stay, for purposes of determining the amount of the refund, begins on the day Monthly Fees starts and ends on the day Monthly Fees cease.” R1 moved out on 10/25/24 without providing a 30-day notice, per the Admission Agreement R1 is responsible for a full month’s fees from the date R1 moved out, which will be 11/23/24.

During an interview with Staff S3, stated R1’s monthly fees started when R1 took possession of the room on 08/05/24 and monthly fees cease on 11/23/24.
During an interview with Staff S2, they were asked if they met with R1’s family regarding R1’s care, S2 stated they had a phone conversation with R1’s daughter regarding 1 on 1 care for R1. Additionally, during interviews with S1 and S2, stated they did not tell R1's family they could not provide care.
During the course of the investigation, the department was unable to find evidence

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20241113145950

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/03/2024

NARRATIVE

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During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

During today's visit the department did not observe or cite any deficiencies.

An exit interview was conducted with Regional Operations Specialist, Kathleen Olson, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC9099 (FAS) - (06/04)

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