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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320431
Report Date: 09/13/2024
Date Signed: 09/13/2024 04:38:13 PM


Document Has Been Signed on 09/13/2024 04:38 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 VERDESFACILITY NUMBER:
198320431
ADMINISTRATOR:KOUL, KELLEYFACILITY TYPE:
740
ADDRESS:25535 HAWTHORNE BLVD.TELEPHONE:
(310) 377-7425
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:115CENSUS: 72DATE:
09/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Krystal JenkinsTIME COMPLETED:
04:45 PM
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On 09/13/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced case management visit for an incident reported. LPA met with Regional Operations Specialist, Krystal Jenkins, and the purpose of today’s visit was explained.
LPA conducted a case management due to two Special Incident Reports (SIR) regarding resident falls one submitted to Community Care Licensing (CCL) on 08/30/24 and the other on 09/02/24. Resident R1 experienced a fall on 08/27/24 resulting in a right distal radius other type extraarticular fracture. Resident R2 experienced a fall on 08/28/24 resulting in a right subtrochanteric fracture requiring surgery.
During today’s visit, LPA toured the facility, checked all hallways, walkways, common rooms, and resident R1 and R2’s room. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. All common rooms and Resident R1 and R2’s room was observed clean, clear, and free of hazards. All rooms was observed with ample lighting.
LPA reviewed resident R1’s Physician’s Report (Exam on 12/27/23), Preplacement Appraisal Information, Needs and Service Plan (updated 05/3/23), hospital discharge paperwork, Internal Incident Report and Progress Notes. LPA observed
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
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: 09/13/2024
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R1 has a minimal history of falls. When LPA conducted a follow-up call the Health Service Director, stated R1 does not have a fall plan.
LPA reviewed resident R2’s Physician’s Report, Resident Care Assessment, MC Assessment, Progress Notes, and Internal Incident Report. When LPA conducted a follow-up call the Health Service Director, stated R2 is considered a fall risk due to their medical diagnosis.

During today’s visit, LPA did not observe any Health and Safety violations.

An exit interview was conducted exit interview with Regional Ops Specialist, Krystal Jenkins, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024
LIC809 (FAS) - (06/04)
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