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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320431
Report Date: 07/17/2026
Date Signed: 07/17/2026 04:47:48 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, 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
05/27/2026 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20260527142624
FACILITY NAME:IVY PARK AT PALOS VERDESFACILITY NUMBER:
198320431
ADMINISTRATOR:JOE SALDANAFACILITY TYPE:
740
ADDRESS:25535 HAWTHORNE BLVD.TELEPHONE:
(310) 377-7425
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:115CENSUS: 90DATE:
07/17/2026
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Brenda MyersTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff locks residents in rooms.
Staff did not communicate with resident's responsible party.
Staff engaged in a verbal altercation in the presence of another resident.
Staff is not allowing resident to have visitations.
INVESTIGATION FINDINGS:
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On 07/17/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Executive Director, Brenda Myers, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The investigation consisted of the following:
During today’s visit, LPA interviewed Staff S4, interviewed Residents R4-10, interviewed W2, and received and reviewed the Durable Power of Attorney (dated 02/22/2017) and the Advance Health Care Directive (dated 02/22/2017).
During initial visit conducted on 06/03/2026, LPA inspected the facility, interviewed Staff S1-S3, S5-S6, interviewed Residents R1-R3, interviewed Witnesses W1-W2, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed, Staff Roster, Resident Information Form, Resident Roster, Admission Agreement, House Rules, email communication, Staff Statement, Witness Statements, Plan of Operation For Dementia Special Care, and City of Torrance Police Department case number 260020612.
The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
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-20260527142624
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: 07/17/2026
NARRATIVE
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information to.
During interviews with Staff S1-S6, were asked if there were any issues with communication between the staff and residents responsible party, two (2) out of six (6) stated there have been no issues with communicating with Resident responsible party and if they have a question they refer them to the Health Services Director. Four (4) out of six (6) stated they had an issue communicating with a Residents family member because the person was asking questions about the resident’s assistance and they are not the Power of Attorney, and they were getting upset due to their policy and procedure that had been implemented. Additionally, Staff S1-S6 were asked who they can communicate with regarding the resident, six (6) out of six (6) stated the Power of Attorney, conservator, or designated Responsible Party.
During interviews with Residents R1-R10, were asked if there have been any issues with communication between the staff and them or their responsible party, ten (10) out of ten (10) stated no, there has been no issues with the communication with staff.
During interviews with Witness W1 and W2, were asked if there have been any issues with communicating with staff, two (2) out of two (2) stated no, they have not experienced any issues with communicating with staff.

Allegation: Staff engaged in a verbal altercation in the presence of another resident


The allegation alleges that staff had a verbal altercation with resident’s family member in front of resident.
During Record Review, LPA received and reviewed an incident report submitted to the department regarding a verbal altercation between staff and a residents family member. According to the report, the resident’s family member was yelling at staff and getting in their face. LPA reviewed statements from the staff and a visitor who witnessed the altercation. Upon review of the Admission Agreement, dated 04/24/2024, on page 12, section 8. Visits and Communication, states “Visitors are welcome at any time provided that they respect the rights of other residents and staff and abide by visitation policies.” Additionally, LPA observed on Appendix , page 2, House Rules that states, “Disruptive or abusive behavior by employes, residents, and resident’s families or guest is not acceptable or permitted.”
During interviews with Staff S1-S6, were asked if there was verbal altercation between staff and a resident’s family, four (4) out of six (6) stated yes there was an altercation with a resident’s family member who was yelling at staff members.
During interviews with Residents R1-R10, were asked if they observed a verbal altercation in their presences, ten (10) out of ten (10) stated no, they have not observed a verbal altercation between a staff member and residents family member.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20260527142624
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: 07/17/2026
NARRATIVE
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Allegation: Staff locks residents in rooms.
The allegation alleges residents’ rooms are locked, residents are not able to exit their room, and visitors cannot enter the room without a key.
LPA observed resident doors have a keyhole to lock and unlock their door from the hallway. There were no deadbolts, latches or chains observed on the residents doors to keep them inside. LPA tested the doors during the visit. A care provider locked a resident’s door from the outside, and the LPA was able to exit the room by pushing down on the door handle, which also unlocks the door. Additionally, LPA observed the resident doors are fire doors.
During Record Review, LPA received and reviewed the Plan of Operation for Dementia Special Care that on page 3, section H. Physical Environment, states “Each room has a lockable door to the hallway which can be opened easily from the inside by the residents by pushing down on the handle. Staff keys are available at all times.” Additionally, in Appendix E, under House Rules states, “Always lock your door when you leave you apartment.” Additionally, LPA received a City of Torrance Police Department, case number 260020612, for two officers who visited the community after receiving a call that residents are being locked in their room. According to S1 the two officers came, walked through, and left with no concerns.
During interviews with Staff S1-S6, were asked if staff lock residents in their room in the Memory Care Unit, six (6) out of six (6) stated resident’s rooms are locked when they are not in their rooms and can go to their rooms at any time and they lock the door once the resident is assisted back to their room and they exit the room and residents can exit at any time.
During interviews with Residents R1-R10, were asked if they have been locked in their room by staff, ten (10) out of ten (10) stated no they have not been locked in their rooms.
During interviews with Witness W1 and W2, were asked if they have seen staff lock residents in their rooms, two (2) out of two (2) stated no, they have not seen staff lock residents in their rooms.

Allegation: Staff did not communicate with resident’s responsible party.


The allegation alleges facility staff refused to provide information to resident’s family member due to not being the Power of Attorney.
During the facility inspection, LPA observed a resident’s family member ask a care provider a question regarding a resident’s care and medication, the care provider referred the family member to go and speak with the Health Service Coordinator because they are unable to provide that information.
During record review, LPA received and reviewed a Durable Power of Attorney dated 02/22/2017 and an Advance Health Care Directive dated 02/22/2017 for Resident R1 and confirmed who the facility can provide
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20260527142624
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: 07/17/2026
NARRATIVE
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During interviews with W1 and W2, were asked if they have observed a verbal altercation between staff and a family member, one (1) out of two (2) stated yes, they observed a resident’s family member yelling at staff, getting in their face, and pointing their face. They additionally stated Staff did not yell, tried to de-escalate the situation, asked them to step back because they were feeling threatened, and the staff remained professional. They stated they stepped in and asked if this was the appropriate place or time for this, and the person continued to yell.

Allegation: Staff is not allowing resident to have visitations


The allegation alleges that a resident’s family member received a call from facility staff informing them they were no longer allowed to visit resident.
During the facility inspection, LPA observed visitors coming and going, in and out of the facility.
During Record Review, LPA received and reviewed the Admission Agreement, dated 04/24/2024, on page 12, section 8. Visits and Communication, states “Visitors are welcome at any time provided that they respect the rights of other residents and staff and abide by visitation policies.” Additionally, LPA observed on Appendix , page 2, House Rules that states, “Disruptive or abusive behavior by employes, residents, and resident’s families or guest is not acceptable or permitted.”
During interviews with Staff S1-S6, were asked if a resident’s family member has been informed, they cannot visit a resident in the facility, two (2) out of six (6) stated yes, pending an investigation of an incident that occurred between staff and a residents family member who became aggressive with staff.
During interviews with Residents R1-R10, were asked if any of their visitors had been denied entry into the facility, ten (10) out of ten (10) stated no, their visitors have not been denied entry into the facility.
During interviews with Witnesses W1 and W2, were asked if they have been denied entry into the facility, two (2) out of two (2) stated no, they have not been denied entry into the facility.

During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) 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(s) is/are unsubstantiated.

During today's visit, LPA did not observe or cite any deficiencies.

An exit interview was conducted with Brenda Myers, Executive Director, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4