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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320431
Report Date: 10/15/2025
Date Signed: 10/15/2025 05:50:40 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
09/30/2025 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20250930101557
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: 74DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Nestor EligioTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff are mismanaging resident's medications.
INVESTIGATION FINDINGS:
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On 10/15/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Executive Director, Nestor Eligio and Breanda 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 Residents R1-R8.
During the initial visit conducted on 10/09/2025, LPA inspected the facility, interviewed Staff S1-S9, conducted a medication review, narcotic count and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, staff Learner Status Report, Staff Relias Transcript, Physician’s Report, Physician’s Orders, Centrally Stored Medications, Medication Destruction Logs, and Medication Administration Records (MAR).

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
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 3
Control Number 11-AS-20250930101557
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: 10/15/2025
NARRATIVE
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Allegation: Facility staff are mismanaging resident’s medications.
The allegation alleges that they have witnessed incidents of medication mismanagement and staff have destroyed narcotic records.

During the facility inspection and file review, LPA participated in a narcotic count for nineteen (19) residents. LPA observed nineteen (19) out of nineteen (19) residents narcotic medications are consistent with properly documented records. Additionally, LPA reviewed Centrally Stored medication and the Medication Administration Record (MAR) for eight (8) residents. LPA observed seven (7) out of eight (8) residents Centrally Stored Medications are not consistent with documented records. LPA did not observe notations of missed or refused medications, or resident out of community.


During record review, LPA received and review the training logs for Medication Technicians (Med Tech), and observed they have all completed 32 hours of shadowing and 8 hours of medication instruction provided on Relias.
During interviews with Staff S1-S9, were asked if residents receive their medications as prescribed, nine (9) out of nine (9) stated yes residents are provided with their medications as prescribed. Additionally, Staff S1-S9, were asked if they have knowledge of medication mismanagement, nine (9) out of nine (9) stated they have no knowledge of medication mismanagement.
During interviews with Residents R1-R8, were asked if they receive their medications as prescribed, eight (8) out of eight (8) stated yes, they receive their medications as prescribed. Additionally, Residents R1-R8 were asked if there was a time they did not receive their medications, three (3) out of eight (8) stated yes, there have been times they did not receive their prescribed medication.

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, Nestor Eligio and Brenda Myers , and a copy of this report ant the appeals rights were provided

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

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250930101557
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: 10/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/25/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
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Administrator will conduct an In-service of medication destruction and logging it properly, and to properly ducment missed medications and the reason why. Administrator will email logs for the in-service and handout to LPA by POC.
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This requirement was not met as evidence by record review, observation, and interviews, Residents R1-R7 have a total of 13 medication errors that were observed during medication review.
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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: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
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