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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320431
Report Date: 05/01/2025
Date Signed: 05/01/2025 12:31:28 PM

Document Has Been Signed on 05/01/2025 12:31 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/
DIRECTOR:		JOSE SALDANAFACILITY TYPE:
740
ADDRESS:25535 HAWTHORNE BLVD.TELEPHONE:
(310) 377-7425
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 115CENSUS: 71DATE:
05/01/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Joe SaldanaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 05/01/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Case Management Visit to the facility listed above. LPA met with Administrator, Joe Saldana, and the purpose of the visit was explained. LPA was granted entry into the facility.
LPA conducted a Case Management Visit to follow up on a Special Incident Report (SIR), submitted on 04/18/2025 and a Death Report submitted on 04/24/2025 for Resident R1. LPA received an incident report on 04/18/25, informing the department R1 had a witnessed fall on 04/12/25. R1 was transferred to Kaiser Harbor City Emergency Room for further evaluation and treatment due to hitting their head. LPA received a Death Report on 04/24/25 for R1 who passed on 04/22/25 while at Kaiser Harbor City Hospital. On the Death Report it was indicated under the Cause of Death that R1 was transferred on 04/12/24 due to a fall. Under the section Conditions Prior to or Contributing to Death, R1 had a hip surgery.
During today’s visit, LPA inspected the fourth (4th) floor, checked all hallways, walkways, common rooms, and resident R1’s room. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. All common
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/01/2025
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rooms and Resident R1’s room was observed clean, clear, and free of hazards. All rooms were observed with ample lighting.
Additionally, during today’s visit, LPA interviewed Staff S1-S4, received, and reviewed documents pertinent to visit. LPA received and reviewed the following documents Staff Roster, Resident Roster, Resident Information Sheet, Admission Agreement, Physician’s Report (dated 02/15/25, 02/10/22, 05/28/21, and 10/06/20), Pre-Placement Appraisal Information (dated 12/10/20), Physician’s Fax Report of Fall (dated 04/13/25, 12/25/24, 08/23/24, 08/28/24, and 11/25/23).
During interviews, R1 was considered a fall risk due to their diagnosis. Additionally, during interviews, LPA was informed R1’s passing was not related to the fall.

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

An exit interview was conducted exit interview with Administrator, Joe Saldana, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC809 (FAS) - (06/04)
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