198320431-11-5-2025-11-AS-EMAZ-DPHTXH-20251219140710

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320431
Report Date: 11/05/2025
Date Signed: 11/05/2025 05:02:34 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
10/08/2025 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20251008205238

FACILITY NAME:	IVY PARK AT PALOS VERDES		FACILITY NUMBER:	198320431
ADMINISTRATOR:	JOE SALDANA		FACILITY TYPE:	740
ADDRESS:	25535 HAWTHORNE BLVD.		TELEPHONE:	(310) 377-7425
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	115	CENSUS:	DATE:	11/05/2025
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Brenda Myer		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff does not ensure residents' behavioral needs are being met.

INVESTIGATION FINDINGS:

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On 11/05/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent Complaint Visit to the facility listed above. LPA met with Executive Director, Brenda Myer, 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 inspected the facility, interviewed Staff S2 a second time, received a Physician’s Report (01/09/2025), Physician’s Fax Report (09/22/2025), Resident R1 and R2 Charting notes, Staff In-Service Logs, and Staff Relias training logs.
During a subsequent visit conducted on 10/17/2025, LPA inspected the facility, interviewed Staff S1, S3-S7, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Reports, Physician’s Fax Report (03/25/2025), and Optum Referral (dated 03/04/2025).
During the initial visit on 10/15/2025, the LPA inspected the facility, interviewed Staff S2, interviewed Residents R1-R8 and received and reviewed documents pertinent to the investigation. The following

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20251008205238

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: 11/05/2025

NARRATIVE

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documents were received and reviewed Staff Roster, Resident Roster, Resident Alert Charting Logs, Shift
Report (dated 10/01/25 through 10/14/25), Incident Reports for R1 (dated 09/17/25 and 09/18/25), copies of text messages from med techs, Resident Assessment, and Individualized Service Plan.

The investigation revealed the following:

Allegation: Staff does not ensure resident’s behavioral needs are being met.
The allegation alleges that residents are expressing aggressive and inappropriate behavior, and the facility staff are not addressing it.

During record review, LPA observed Incident Reports dated 09/17/2025 and 09/18/2025 regarding an incident that occurred between Resident R1 and staff where the resident was upset and yelling at the staff. According to Staff who witnessed the incident, reported that the resident did not threaten, intimidate, or touch the Staff, but was in the staff’s face expressing their frustration. LPA did observe a Physician’s Fax Report, dated 09/22/2025, that was sent to R1’s primary care physician (PCP) informing them of the incident and behavior. LPA reviewed Resident R1’s Physician’s Report, dated 01/09/2025, that address R1’s behavioral expression.

During record review, LPA observed in R2’s Physician’s Reports, dated 07/23/2024 and 10/25/2023, that indicates R2 does not express inappropriate or aggressive behavior. LPA did observe in R2’s Charting Notes there were eleven (11) instances of confusion documented since 01/01/2025. LPA reviewed Resident R2’s Healthcare Provider Communication forms that indicate R2 is seen regularly by their physician, home health nurse, and physical therapist.
LPA received and reviewed staff in-service logs for Behavior Expression, Redirection and Dementia vs. MCI conducted on 05/29/2025. LPA received and reviewed seven (7) staff Relias training that include Managing Challenging Behaviors, Psychosocial Needs, Communication, and Recognizing Change of Condition.
During interviews with Staff S1-S7, were asked if management follow-up with incidents of behavioral expression, seven (7) out of seven (7) stated when it is reported that a resident is experiencing behavioral expression the residents Primary Care Physician and responsible party is notified. During an interview with S2 stated if a resident is exhibiting behavioral expression, they will request a urinalysis and/or psych evaluation when speaking with the PCP.
During interviews with Residents R1-R8, were asked if staff address any change of condition/behavior exhibited by them or other residents, eight (8) out of eight (8) stated yes, staff address any changes they

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20251008205238

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: 11/05/2025

NARRATIVE

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see immediately.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation 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.

LPA did not observe or cite any deficiencies.

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025

LIC9099 (FAS) - (06/04)

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