198601661-10-20-2025-11-AS-SCIS-DPR353-20251226165600

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 06/20/2025
Date Signed: 10/20/2025 11:35:07 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, 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
04/18/2025 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20250418112036

FACILITY NAME:	IVY PARK AT PLAYA VISTA		FACILITY NUMBER:	198601661
ADMINISTRATOR:	KHATERA BAHADORY		FACILITY TYPE:	740
ADDRESS:	5555 PLAYA VISTA DR		TELEPHONE:	(310) 437-7178
CITY:	PLAYA VISTA	STATE: CA	ZIP CODE:	90094
CAPACITY:	102	CENSUS: 73	DATE:	06/20/2025
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Nestor Mendez		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not follow proper eviction protocol
Staff did not communicate with responsible party regarding resident's care

INVESTIGATION FINDINGS:

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** This LIC 9099 report has been amended and supersedes the original report dated 06/20/2025. The findings remain unchanged.**
On 06/20/2025, the California Department of Social Services/Community Care Licensing Division (CDSS/CCLD) Licensing Program Analyst (LPA) LPA Pamela Bunker conducted a subsequent visit to gather information regarding the above allegations. LPA Bunker met with Nestor Mendez, Executive Director, and explained the purpose of the visit. LPA was granted entry to the facility.
The investigation consisted of the following: On 05/29/2025 and 06/19/2025, the Department requested, reviewed, and obtained copies of the following documents: Staff Personnel Report (dated 03/29/2025), Resident Roster (dated 05/29/2025), Resident 1 (R1) Records (dated 03/06/2023), Admission Agreement (dated 03/06/2023), Identification and Emergency Information (dated 03/06/2023), Physician's Report (dated 03/08/2023), Medical Assessment (dated 03/08/2023), Medication Administration Records (MARs) (dated 03/06/2023-04/05/2025), Consent Forms (dated 03/06/2023), Functional Capability Assessment (dated 03/06/2023), Preplacement Appraisal Information (dated 03/06/2023), See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
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 4

Control Number 11-AS-20250418112036

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 PLAYA VISTA	FACILITY NUMBER: 198601661
	VISIT DATE: 06/20/2025

NARRATIVE

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Continued LIC9099-C page #2

Appraisal, Needs and Service Plan (dated 03/06/2023), Progress Notes (dated 04/25/2025), Kaiser Permanente Hospital Admission and Discharged Records (03-15/2024-03/19/2024). Kaiser Permanente Care at Home Metro LA Hospice Program (03/19/2024, 03/26/2024, 04/04/2024), Planet Home Health Care Inc. (dated 01/26/2024).

The investigation revealed the following:
Allegation #1: Staff did not follow proper eviction protocol
It is being alleged that Resident 1 (R1) was denied reentry to the facility after being discharged from the hospital and was not provided with the required 30-day eviction notice.

LPA Bunker interviewed staff members S1 through S4 (S1-S4) regarding the allegation that staff did not follow proper eviction protocol. 2 out of 4 staff stated that they were not employees of Ivy Park at Playa Vista at the time of the incident and had no knowledge of the allegation. 2 out of 4 staff also stated that all employees mentioned in the complaint report are no longer working at the facility. 2 out of 4 staff states that the facility had no records indicating that R1 received a 30-day eviction notice, nor were there any, records or special incident reports stating R1 was told not to return to the facility after being discharged from USC Verdugo Hills Psychiatric Hospital.

Interviews with S3-S4 (2 out of 4) staff stated that they were employed at the facility during the incident and reported that R1 had aggressive behavior toward staff and other residents.

4 out of 4 staff interviewed stated that there were no surveillance cameras to capture the incident. 4 out of 4 staff confirmed that eviction protocols are handled by the Business Office Administration, not by the caregivers. 2 out of 4 staff members interviewed stated that the facility does follow eviction protocols and communication with the resident's responsible parties. No one currently employed at the facility had any additional information.

See continued LIC812-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
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 4

Control Number 11-AS-20250418112036

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 PLAYA VISTA	FACILITY NUMBER: 198601661
	VISIT DATE: 06/20/2025

NARRATIVE

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Continued LIC9099-C page 3

On 06/19/2025 at 11:48 a.m., LPA Interviewed the reporting party (W1) via telephone. The W1 stated that the facility's Executive Director (ED) at the time, along with a nurse (name unknown), informed the W1 that they were no longer working for Ivy Park after their assessment of R1 and that R1 would not be allowed to return to the facility. The W1 stated that the ED offered other referrals but suggested Silverado In Rolling Hills. The W1 stated on 04/05/2024, R1 was discharged from USC Verdugo Hills Psychiatric Hospital and admitted to Silverado in Rolling Hills.

On 06/19/2025 at 10:32 a.m., LPA Bunker contacted Silverado in Rolling Hills (Facility #198320514) and spoke via telephone to Executive Director (ED) Christine Hale, who confirmed that R1 was admitted to Silverado in Rolling Hills on 04/05/2024, ED also confirmed that R1 was on Hospice care and passed away on 11/19/2024.

LPA Bunker reviewed the facility records and found no evidence of a 30-day eviction notice or an updated assessment.

Based on interviews and documentation, the Department has no records to prove that staff failed to follow proper eviction protocol.

See continued LIC9099-C page 4

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
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: 3 of 4

Control Number 11-AS-20250418112036

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 PLAYA VISTA	FACILITY NUMBER: 198601661
	VISIT DATE: 06/20/2025

NARRATIVE

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Continued LIC9099-C page 4

Allegation #2: Staff did not communicate with the responsible party regarding the resident's care
Interviews were conducted with staff members 1 through 4 (S1-S4) and residents 2 through 7 (R2-R7). Both staff and residents reported that staff ensures that the staff communicates with residents' responsible parties regarding their care. 4 out of 4 staff stated all incidents are reported and that residents' responsible parties are notified in a timely manner.

6 out of 7 residents interviewed stated that staff contact their responsible parties regarding any incident involving them. Resident (1) R1 no longer resides at the facility, is deceased, and was not available for an interview.

Based on interviews and documentation, the Department has no evidence to support the allegation that staff failed to communicate with the responsible party regarding the resident's care.
Based on interviews conducted, the department did not find sufficient evidence to support the allegation. 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.

Copies of the Complaint Investigation Report (LIC9099 and LIC9099-Cs) were provided to Nestor Mendez, the Executive Director.

There were no deficiencies cited.

An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC9099 (FAS) - (06/04)

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