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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320431
Report Date: 07/24/2025
Date Signed: 07/24/2025 05:44:47 PM

Document Has Been Signed on 07/24/2025 05:44 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:		JOE SALDANAFACILITY TYPE:
740
ADDRESS:25535 HAWTHORNE BLVD.TELEPHONE:
(310) 377-7425
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 115CENSUS: 71DATE:
07/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Amber LambertTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 07/24/25, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Business Office Director, Amber Lambert, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve 115 non-ambulatory residents aged 60 and over, of which 8 may be bedridden. The facility has an approved hospice waiver for 20.
Physical Plant/Structure The facility is a five-story structure located in a commercial neighborhood. The ground floor is the car park and entrance, the first and second floors are Assisted Living, the third floor is Memory Care, and the fourth floor is Memory Care. There is a total of 37 Assisted Living units and 61 Memory Care units, each unit contains a bathroom. On the first floor there are 3 common bathrooms, beauty salon, 2 common areas with a TV, computer area, dining area, bistro area, industrial kitchen, storage rooms, laundry room, offices, and staff break room. The second floor consists of an activity room/theater room, bistro, wellness center, laundry room, staff offices, and storage rooms. The third and fourth floor consist of a kitchen, dining room, activity room, TV room, shaded outdoor patio, staff offices, storage room, and laundry room. During the tour, LPA did not observe any bodies of water on the premises. The outside patio/garden area has a shaded area with tables and chairs. The gates exiting the patio are egressed, and work properly. All outside walkways were observed to be clean, clear, and free of obstructions, debris, and hazards. All windows, screens, curtains, and blinds were observed to be in good repair and operate properly.
Rooms LPA inspected eight (8) resident rooms, 117, 125, 204, 215, 304, 321, 403, and 412 and observed them to be clean and in good repair. LPAs observed the rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. Residents have the option to furnish
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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: 07/24/2025
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their room, or the facility has furniture available if residents require it. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. Residents do have
the option to use their personal linens, or the facility has a supply available. LPA observed an additional supply of linens in a storage room. All linens and mattresses were observed in good condition. All rooms were observed to have ample lighting.
Bathrooms LPA observed all bathrooms to be operable and within Title 22 regulations. The toilet, facets, and shower work properly. The bathrooms were observed clean. The showers were observed with secured safety handrails, nonskid mats, and a shower chair. The showers were observed to be free of mold and mildew. LPA observed storage space for residents’ hygiene products. LPA observed an ample supply of towels and hygiene products available for residents or residents have the option to supply their own. The water temperature in rooms inspected and bathrooms in common areas measured between 108-degrees and 115.4-degrees Fahrenheit.
Kitchen LPAs observed the industrial kitchen to be clean and sanitary during the time of visit. LPA observed all appliances to be operable and in good repair. LPA observed an ample supply of cookware, dishware, and cutlery. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All foods were observed properly dated, labeled, packaged, and stored. The freezer temperature measured 0-degrees Fahrenheit, and the refrigerator temperature measured 45-degrees Fahrenheit. LPA observed knives and sharps to be secured and are inaccessible to residents. LPA observed a menu posted in the dining room. The menu and kitchen were last reviewed and inspected by a dietitian on 06/25/2025. The third and fourth floor kitchens were observed to be clean and sanitary. LPA observed a supply of snacks and drinks available for residents at any time LPA observed cleaning supplies and sharps to be secured in a locked storage room and are inaccessible to residents. All trash cans were observed with tight fitting covers.
Common Rooms LPA observed the facility was appropriately furnished during the time of the visit. LPA observed all common rooms to have ample seating to accommodate residents. LPAs observed all dining rooms to have ample seating to accommodate residents. In the activity room, LPA observed arts, crafts, games, puzzles, and reading material available for residents. LPA observed a daily and monthly activity schedule. All walkways, hallways, and stairs in the facility were observed to be clean, clear, and free of hazards and obstructions. The facility was kept at a comfortable temperature of 72-degrees Fahrenheit. All rooms and hallways were observed to have ample lighting.
Files LPAs observed resident files secured in the locked wellness room and are inaccessible to residents. LPA reviewed the files for eight (8) residents and observed they have the required documents. The staff files are secured in the business office and are inaccessible to residents. LPA reviewed the file for the
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 07/24/2025
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the Administrator and six (6) staff and observed they have the required documents, certification, clearance, and training. LPA Observed the administrators Administrator Certificate is valid till 08/02/2025. LPA informed Business Office Manager that Licensing fees are due on 07/24/2025 and provided the PIN.
Safety LPA obseved smoke detectors on each floor and carbon monoxide detectors in each resident unit and found them to be operable. When smoke detectors are triggered they close. LPA observed multiple fully charged fire extinguisher last serviced on 12/03/2024, throughout the facility. The last Fire Prevention Inspection was conducted on 05/07/2025. The last emergency drill was conducted on 06/27/2025. LPA observed evacuation chairs at each staircase. The facility has a working landline telephone. LPA observed the facility’s Emergency and Disaster Plan posted and last updated on 03/31/2025. LPA observed all required posting, posted throughout the facility. LPA received and reviewed a copy of the liability insurance through Acord valid till 05/01/2026.
Medications LPA observed medications secured in locked medication carts, secured in locked medication rooms. Medications are inaccessible to residents. LPA observed medications to be in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR) for six (6) residents. LPA observed six (6) out of six (6) resident’s medications are consistent with properly documented records. LPA observed a fully stocked First Aid kit with a current manual, in the wellness room. LPA observed additional First Aid supply secured in a storage room.
Infection Control LPA observed a sanitizing station upon entry, in the restrooms, and throughout the facility. LPA observed required infection control signs posted throughout the facility. LPA observed a 30-day supply of Personal Protective Equipment (PPE).

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


An exit interview was conducted with Business Office Director, Amber Lambert, and Regional Health Services Director, Jennifer Frost, 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: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
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