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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320431
Report Date: 03/13/2025
Date Signed: 03/13/2025 05:13:52 PM

Substantiated


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
02/12/2025 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20250212160256
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: DATE:
03/13/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jose SaladanaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff do not respond to residents calls for assistance in timely manner resulting in resident falls
INVESTIGATION FINDINGS:
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On 03/13/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced complaint visit to the facility listed above. The department met with Executive Director, Jose Saladana, 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 received additional Device Activity Reports for resident pendants, Incident Reports, Healthcare Provider Communication, Resident R11 Charting Notes, and incontinent supply review.
During a subsequent visit on 03/05/2025, LPA toured the facility, tested resident’s pendants, and interviewed Residents R2-R9.
During the initial visit conducted on 02/20/2025, LPA toured the facility, interviewed Staff S1-S10, interviewed Residents Responsible Party W1, and received documents pertinent to the investigations. The following documents were received and reviewed, Staff Roster, Resident Roster, Preplacement Appraisal Information, Physician’s Report, Assessment Summary, Charting Notes, Centrally Stored Medications, Needs and
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
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 7
Control Number 11-AS-20250212160256
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: 03/13/2025
NARRATIVE
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 Service Plan, Healthcare Provider Communication, pendant Device Activity Report, and Staff Training Logs.

The investigation revealed the following:

Allegation: Staff did not respond to residents calls for assistance in a timely manner resulting in resident falls


The allegation alleges that a Resident pressed their call button for assistance and when staff did not come the resident got up and had a fall.
LPA received and reviewed pendant Device Activity Report and observed on 02/08/2025 at 11:07:21PM R1 pressed their pendant, it was cleared at 11:31:54AM, taking staff a total of 24 minutes and 33 seconds to respond. Additionally, LPA observed R1 pressed their pendant at 2:37:13AM, that was cleared at 3:00:25AM, taking staff a total of 23 minutes and 12 seconds to respond to the call. R1’s arrival to the Emergency Room was on 02/09/2025, at 3:46AM. Additionally, LPA reviewed a Special Incident Report (SIR) for Resident R11, that states R11 had a fall on 02/14/2025. LPA reviewed the Device Activity Report and observed on 02/14/2025 at 8:57:29AM R11 pressed their pendant, it was cleared at 9:27:52AM, taking staff a total of 30 minutes and 23 seconds to respond. LPA received and reviewed staff Charting Notes for R11 that states on 02/14/2025 Resident had an unwitnessed fall approximately around 9:15AM and Resident was found on the floor.
During interviews with Staff S1-S10, were asked if any residents experienced a fall
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20250212160256
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: 03/13/2025
NARRATIVE
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while waiting for assistance, two (2) out of ten (10) Staff stated residents have experienced a fall while waiting for assistance.
During interviews with Residents R2-R9, were asked if they experienced a fall due to lack of assistance, five (5) out of eight (8) stated they have not experienced a fall due to lack of assistance.
During interviews with Witnesses (W1 and W2), were asked if a resident experienced a fall due to lack of assistance, one (1) out of two (2) stated a resident experienced a fall due to lack of assistance.

During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

An exit interview was conducted with Executive Director, Jose Saladana, and a copy of this report and the Appeals Rights was provided.

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

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
02/12/2025 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20250212160256

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: DATE:
03/13/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jose SaladanaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are taking resident's incontinent supplies
Staff do not check on resident every 2 hours
INVESTIGATION FINDINGS:
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On 03/13/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced complaint visit to the facility listed above. The department met with Executive Director, Jose Saladana, 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 received additional Device Activity Reports for resident pendants, Incident Reports, Healthcare Provider Communication, Resident R11 Charting Notes, and incontinent supply review.
During a subsequent visit on 03/05/2025, LPA toured the facility, tested resident’s pendants, and interviewed Residents R2-R9.
During the initial visit conducted on 02/20/2025, LPA toured the facility, interviewed Staff S1-S10, interviewed Residents Responsible Party W1, and received documents pertinent to the investigations. The following documents were received and reviewed, Staff Roster, Resident Roster, Preplacement Appraisal Information, Physician’s Report, Assessment Summary, Charting Notes, Centrally Stored Medications, Needs and
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20250212160256
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: 03/13/2025
NARRATIVE
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Service Plan, Healthcare Provider Communication, pendant Device Activity Report, and Staff Training Logs.

The investigation revealed the following:

Allegation: Staff are taking resident’s incontinent supplies.


The allegation alleges a staff member came into a resident’s room and left with a trash bag full of their incontinent supplies and supplies are needing to be replaced more frequent.
LPA received and reviewed the list of residents who receive incontinent assistance and have supplies delivered, brought in, or supplied by the facility. During the facility tour, LPA observed an ample supply of incontinent supplies to be used for residents if they run out of their supply of incontinent products.
During interviews with Staff S1-S10, were asked if staff take other residents incontinent supplies to use for other residents, ten (10) out of ten (10) stated they do not take other resident’s incontinent products to use on other residents.
During interviews with Residents R2-R9, were asked if staff have taken their incontinent products from their room to use on other residents, one (1) out of eight (8) stated they have seen staff take their incontinent products from their room.
During interviews with Witnesses W1 and W2, were asked if any of their resident’s incontinent products were taken to use on other residents, one (1) out of two (2) indicated their resident said staff has taken their incontinent products from their room.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20250212160256
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: 03/13/2025
NARRATIVE
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Allegation: Staff do not check on resident every 2 hours.
The allegation alleges staff do not check on resident every 2 hours.
During file review, LPA received and reviewed Healthcare Provider Communication, for Resident R1, on 12/05/2024 LPA observed the provider from Torrance Memorial Medical Center indicates the Outcome of Visit: “Check in every 2 – 3 hours for toileting. LPA received and reviewed Resident R1’s Assessment Summary that indicates R1 “is at moderate risk for falling according to the Fall Risk Assessment.” LPA received and reviewed Resident R1’s Care Plan dated 01/10/2023, indicates R1 has had a fall with injury in the past, the Goal is to minimize fall risk by “supervision, not leaving me unattended”, and the Intervention is to “Check on me at frequent intervals to see if I need any assistance.”
During interviews with Staff S1-S10, were asked how often they check on residents, five (5) out of ten (10) stated they check residents every hour, three (3) out of ten (10) stated they check every 2 hours, and two (2) out of ten (10) stated they check every 30 minutes. Additionally, during interviews, four (4) out of ten (10) stated for residents who are a fall risk they check on them every 30 minutes.
During interviews with Residents R2-R9, was asked if staff come and check if they need assistance throughout the day, eight (8) out of eight (8) stated staff check on them a few times a day.
During the course of the investigation, LPA was unable to find evidence to support the allegations. Although the allegations 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.
An exit interview was conducted with Executive Director, Jose Saladana, and a copy of this report was provided
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20250212160256
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in all Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) to
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Administrator will develop a plan, conduct an in-service with Care staff, e-mail LPA with plan and in-service conducted by POC.
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to care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
Based on record review R1 and R11 experienced a fall after pressing their pendants and waiting an extened period of time for assistance.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7