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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320432
Report Date: 08/23/2026
Date Signed: 08/23/2026 02:20:33 PM

Document Has Been Signed on 08/23/2026 02:20 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:IVY PARK AT PLAYA VISTAFACILITY NUMBER:
198320432
ADMINISTRATOR/
DIRECTOR:		ELIGIO, NESTORFACILITY TYPE:
740
ADDRESS:5555 PLAYA VISTA DRIVETELEPHONE:
(310) 437-7178
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY: 102CENSUS: 83DATE:
08/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:42 AM
MET WITH:Olga RayoTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the facility annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met Health Service Director Malia Hatem and explained reason for visit. Administrator Olga Rayo arrived shortly.

There are currently 83 elderly residents, 60 years and older, residing in the facility. The facility is licensed for (102) residents with age range 60 and over. 102 non-ambulatory, of which four (4) may be bedridden. Hospice waiver granted for twenty (20).

The facility has six (6) floors which consists of: rooms 123-124, 127, 133-135, private dining, restaurant, bistro, kitchen, lobby, two (2) living rooms, lounge, laundry room, and three (3) solariums. The second floor consists of: rooms 208-213, 215-216, 218-222, 224-227, activity studio, outdoor terrace, salon, hydro spa, and laundry room. The third floor (memory care) consists of: rooms 308-313, 315-316, 318-322, 324-327, living room, dining room, outdoor terrace, kitchen, laundry room, activity room, and storage. The fourth floor (memory care) consists of: rooms 408-413, 415-416, 418-422, 424-427, living room, kitchen, dining room, outdoor terrace, laundry room, activity lounge, and storage. The fifth floor consists of: rooms 505, 508-509, 511 – 515, 517-518, 520 – 522, activity studio, two (2) storages, and laundry room. The sixth floor consists of: rooms 603, 605-606, 609-612, 614-615, 617, and one storage.

SEE LIC 809C

David Sicairos
Christian Gutierrez
DATE: 08/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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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Document Has Been Signed on 08/23/2026 02:20 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/23/2026 at 01:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198320432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in twelve (12) out of twelve (12) rooms toured did not have required water temperature which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2026
Plan of Correction
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Administrator had maintenance lower water tempreature at time of visit. A water log will be created and send to LPA on 08/31/2026 with water readings.
R# 135-128.6, R# 134 -127.9, R# 219-129.1,R# 224-134.6,R#310-131.3. R# 318-102.2,R#422-129.3,R# 425-129.5,R#514-129.2,R#517-129.9, R#610-129.3, and R#617-132.9.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/23/2026 02:20 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/23/2026 at 01:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198320432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above 1st floor hallway had boxes on floor which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Administrator will send LPA pictures once boxes are removed and remind staff to no leave anything on floor that may be a tripping hazard to residents.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above last emegency drill was in march of 2026 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Administrator will conduct drill with staff and send to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2026


LIC809 (FAS) - (06/04)
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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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198320432
VISIT DATE: 08/23/2026
NARRATIVE
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LPA toured the entire building and observed the following: First floor has boxes that were left from a delivery in hallway floor that could be a tripping hazard to residents. Administrator instructed maintenance to move boxes at time of visit. Resident bedrooms were randomly chosen for review on each floor 1st floor (R# 135 and R# 134) 2nd floor (R#219 and R#224) 3rd floor (R#310 and R#318) 4th floor (R3 422 and R#425),5th floor (R#514 and R#517) and 6th floor (R#610 and R#617). Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The residents’ bathrooms have the required grabs bars and non-skid mat. The hot water was between 102.2-134.6 degrees, which is not within the required 105 - 120 degrees. Fire extinguishers were observed throughout the facility. Cleaning supplies and toxic substances are inaccessible to residents. Kitchen was inspected and there is a sufficient supply of 2-day perishable and 7-day non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the activity room, dining room, and living room. These areas are clean and have the required furniture. There are no firearms or weapons stored at the facility. Evacuation chairs were observed at each stairwell. All required postings were observed throughout the facility. The facility does not have a swimming pool or bodies of water on the premises.

LPA checked first aid kit that included all of the required items along with the manual. Six (6) staff files were reviewed and included Criminal clearance record, and health screening with TB. Six (6) residents files were reviewed and included physicians report with TB clearance. R3 needed updated 602 TV was given. Last fire/earthquake drill was conducted in March of 2026 deficiency given. Infectious control plan was reviewed. Random resident medications were reviewed. Medications are centrally stored and locked. No errors were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit will be documented on LIC809-D. Exit interview was held and a copy of the report with appeal rights was given to Administrator Olga Rayo.

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NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2026
LIC809 (FAS) - (06/04)
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