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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601661
Report Date: 09/26/2024
Date Signed: 09/26/2024 12:43:35 PM

Document Has Been Signed on 09/26/2024 12:43 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 PLAYA VISTAFACILITY NUMBER:
198601661
ADMINISTRATOR/
DIRECTOR:		TUCKER, SABRINAFACILITY TYPE:
740
ADDRESS:5555 PLAYA VISTA DRTELEPHONE:
(310) 437-7178
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY: 102CENSUS: 78DATE:
09/26/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:19 AM
MET WITH:Executive Director Khatera BahadoryTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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On 09/26/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual continuation inspection and met with the Executive Director Khatera Bahadory.

The facility is licensed to serve 102 non-ambulatory of which 18 may be bedridden. It has a hospice waiver for 20 residents. The facility currently has two bedridden residents and three hospice residents. The facility has six floors which consist of resident bedrooms, bathrooms, living room, activity rooms, dining room, laundry rooms, storage rooms, beauty shop, reflection rooms, wellness center, kitchenettes, and main kitchen. Delayed egress is located on the third and fourth floors (Memory Care). The facility has a Call Light signal system, which is monitored by a beeper carried by staff and is also registered on a central computer located in the Wellness Center on the second floor. The system is activated by a pendent or pull cord from each resident bathroom and bedroom. In addition the signal system is activated when any exit is opened (excluding Memory Care).



On 09/05/24, the Administrator accompanied LPAs Cloyd and Hollie Enriquez inside the facility during this inspection. LPA Enriquez inspected the first floor, second floor (rooms 209, 212, 221, and 225), and stairwells. LPA Cloyd inspected the third floor (rooms 312, 320, and 326), fourth floor (410, 412, 421, and 426), fifth floor (rooms 508, 509, 515, and 522), and sixth floor (rooms 605, 611, and 615). Continue to LIC 809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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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 PLAYA VISTA
FACILITY NUMBER: 198601661
VISIT DATE: 09/26/2024
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Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat or no-skid flooring was in place. The hot water temperature properly measured at 105.5 degree F (second floor common bathique room), around 115 degree F (rooms 209, 212, 221, and 225), 105.1 degree F (room 410), 113.8 degree F (room 508), and 118.7 degree F (room 611). There are no security bars or weapons on the premises. LPA Enriquez toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. Common areas were clean and clear of hazards. Doorways were free of obstructions. Fire extinguisher, last serviced in October 2024, November 2024, and December 2024 was observed throughout the facility.

Eleven staff records were reviewed, eleven out of eleven staff records had required criminal record clearances or criminal record exemptions.

Nine resident records were reviewed and, nine out of nine resident records had medical assessments. Two residents’ medication was reviewed.

On 09/26/24 11:30 AM, the Executive Director and Administrator toured outside grounds and no bodies of water were observed. Walkways around the facility were clear of hazards. First Aid kits are available on each floor. The last fire drill occurred on 09/16/24.The Executive Director indicated that fire inspection are conducted with the drills.
No deficiencies are being cited.

An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Executive Director Khatera Bahadory.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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