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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 04/10/2024
Date Signed: 11/15/2024 11:15:54 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/08/2024 and conducted by Evaluator David Espana
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240408104450
FACILITY NAME:IVY PARK AT PLAYA VISTAFACILITY NUMBER:
198601661
ADMINISTRATOR:TUCKER, SABRINAFACILITY TYPE:
740
ADDRESS:5555 PLAYA VISTA DRTELEPHONE:
(310) 437-7178
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY:102CENSUS: 78DATE:
04/10/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator/Executive Director, Sabrina Tucker TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are administering resident's medication against her and POA's will.
Staff are not honoring resident's POA document.
Staff are not allowing resident to have visitors.
Staff are not allowing resident use of the phone.
INVESTIGATION FINDINGS:
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****This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 04/10/2024.**
On 04/10/2024 at 9:10 am Licensing Program Analyst (LPA) David España conducted an unannounced complaint visit to Ivy Park at Playa Vista to initiate a complaint investigation. LPA España was greeted by Executive Director, Sabrina Tucker. LPA España explained the purpose of the visit and was allowed entrance to the facility grounds.

The investigation consisted of the following: On 04/10/2024 Licensing Program Analyst (LPA) David España conducted a tour of the physical plant. LPA España request the following documents: Dated weekly employee time schedule; RCFE License Certificate; Verification of first aid training; Verification of Staff Training; Personal Property Procedures (LIC 9059); LIC 613C - Personal Rights; LIC 622 - Centrally Stored Medication and Destruction Record. LIC 601 - Identification and Emergency Information; LIC 602A - Physician's Report; LIC 603A - Resident Appraisal; 604A - Admission Agreement; Home health agency (list of all who provide services to residents/contact information); Daily notes/Staff notes/Facility notes (1-month records); and Admission agreements. LPA interviewed resident 1-resident 6. LPA interviewed staff #1-#6 (S1-S6).
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Benita YatesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
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 6
Control Number 11-AS-20240408104450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 198601661
VISIT DATE: 04/10/2024
NARRATIVE
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 Allegation #1– Staff are administering resident's medication against her and POA's will.

On 4/10/2024 LPA Espana conducted interviewed with 6 staff members (S1-S6). LPA asked about staff if any resident's medication was administered against their will or POA's will. Of those interviewed 6 out of 6 stated that they did not hear or know of medication being provided against residents or POA’s will. On 4/10/2024 LPA Espana interviewed 6 residents (R1-R6). Of those interviewed, 6 out of 6 communicated that they disagreed with the statement because they have had no issues with medications being provided by staff.
On 4/10/2024 LPA Espana interviewed the Administrator who stated that for residents who refuse, the facility staff does not administer medication. The Administrator stated that the facility staff document resident refusal and call the doctor to let them know. The Administrator stated that, there were no residents who have refused medication at the time of visit.

Based on interviews and observations there is insufficient evidence to support the allegation: Staff are administering resident's medication against her and POA's will. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
SUPERVISOR'S NAME: Benita YatesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20240408104450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 198601661
VISIT DATE: 04/10/2024
NARRATIVE
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Allegation #2: Staff are not honoring resident's POA document.

On 4/10/2024 LPA Espana conducted interviewed with 6 staff members (S1-S6) regarding the allegation. Of those interviewed 5 out of 6 staff members, communicated that the facility honors all residents’ POA documents. On 4/10/2024 LPA Espana interviewed Residents #1-#6 (R1-R6). Of those interviewed, 4 out of 6 residents, communicated that they have not heard anything like that. On April 10, 2024, LPA España reviewed facility documents and found Durable Power of Attorney for Health Care signed by POA of R1.

Based on interviews and observations there is insufficient evidence to support the allegation: Staff are not honoring resident's POA document. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
SUPERVISOR'S NAME: Benita YatesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20240408104450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 198601661
VISIT DATE: 04/10/2024
NARRATIVE
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Allegation #3: Staff are not allowing resident to have visitors.

On 4/10/2024 LPA España interviewed 6 staff members, of those interviewed, with 5 out of 6 stated that the facility allows visits for the residents in care. Interviews with 6 out of 6 residents, communicated that they always have visitors no matter the day. There is no problem with visits at the facility. Interview with the Administrator Sabrina Tucker stated that the residents are allowed to have visitors. On April 10, 2024, LPA España reviewed files and found that the Residential Agreement allows family visits anytime, provided visitors residents' and staff rights, and follow visitation policies. Overnight stays require written notification to the Executive Director, and all visitors must register at the front desk.



Based on interviews and observations there is insufficient evidence to support the allegation: Staff are not allowing resident to have visitors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
SUPERVISOR'S NAME: Benita YatesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20240408104450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 198601661
VISIT DATE: 04/10/2024
NARRATIVE
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Allegation #4: Staff are not allowing resident use of the phone.

On 4/10/2024 LPA España interviewed 6 staff members (S1-S6), of those interviewed, 5 out of 6 communicated that the facility does allow residents to use phones and receive calls from families. LPA Espana interviewed 6 residents, of those interviewed 6 out of 6 communicated that they have their personal cell phones and do understand there is a blue telephone on each floor they have access to daily.

Based on interviews and observations there is insufficient evidence to support the allegation: Staff are not allowing resident use of the phone. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were issued during this complaint investigation visit.

An exit interview was conducted with the Administrator Sabrina Tucker and a copy of this report was printed and given.

SUPERVISOR'S NAME: Benita YatesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20240408104450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 198601661
VISIT DATE: 04/10/2024
NARRATIVE
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SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6