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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601661
Report Date: 10/04/2023
Date Signed: 10/04/2023 12:04:52 PM


Document Has Been Signed on 10/04/2023 12:04 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:TUCKER, SABRINAFACILITY TYPE:
740
ADDRESS:5555 PLAYA VISTA DRTELEPHONE:
(310) 437-7178
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY:102CENSUS: 84DATE:
10/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:06 AM
MET WITH:Sabrina Tucker, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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On 10/04/2023 at 8:30 AM, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced subsequent – Annual Continuation Inspection and met with the Administrator Sabrina Tucker.

LPM and LPA toured the second floor of the facility to inspect resident room and review required oxygen postings. Administrator, LPM and LPA toured outside premises to inspect the construction material.

LPM and LPA review nine resident admission files and three resident health files.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and left with Sabrina Tucker.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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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Document Has Been Signed on 10/04/2023 12:04 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)

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Type B
10/26/2023
Section Cited
CCR87705(c)(6)

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Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
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The administrator will obtain a medical assessment and conduct a reppraisal for resident #7. Proof of correction will be submitted to CCL via email to regina.cloyd@dss.ca.gov
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Based on record review, the licensee did not comply with the section cited above. LPA did not observe an updated medical assessment nor signed reappraisal for resident # 7, which poses a potential health risk to person in care.
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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.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/04/2023 12:04 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2023
Section Cited
CCR
87411(f)

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All personnel... shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test performed by a physician...
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Administrator will obtain LIC 503 Health Screenings for staff (S2, S4, S7, and S9) and email proof of correction to CCL via email to regina.cloyd@dss.ca.gov
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This requirement is not met as evidenced by: During record review on September 20, 2023, LPA did not observe LIC 503 Health Screening Report for staff (S2, S4, S7, and S9), which poses a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
LIC809 (FAS) - (06/04)
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