198601661-9-18-2025-11-AS-SCIS-DU22GR-20260512172329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 09/18/2025
Date Signed: 09/18/2025 04:51:25 PM

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
04/18/2025 and conducted by Evaluator Troy Watson

COMPLAINT CONTROL NUMBER: 11-AS-20250418093426

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:	0	CENSUS: 72	DATE:	09/18/2025
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	EXECUTIVE DIRECTOR - NESTER MENDEZ		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff did not provide responsible party with a refund.
Staff did not communicate with responsible party regarding resident's care.
Staff charged resident for services not rendered.
Staff did not provide responsible party with resident's facility records.
Staff did not provide resident with a reappraisal.

INVESTIGATION FINDINGS:

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On 09/18/2025 Licensing Program Analyst's (LPA) Troy Watson conducted a subsequent visit to deliver findings regarding the above allegations(s). LPA met with the Executive Director Nestor Mendez and the purpose of the visit was explained. LPA was granted entry to the facility.

Investigation consisted of the following:

On 04/23/2025 the department requested and obtained copies of, the LIC500 Personnell Report, and Resident Roster. On 04/25/25 the department interviewed Staff#1 – Staff#4 (S1-S4).On 09/18/2025 LPA Watson requested reviewed and obtained copies of the Staff Roster, Resident Roster,Chase Check(08/06/25) ,Admission Agreement and Notice of Care Increase (01/25/2024) . LPA Watson toured the facility with Jandra Bishop and found the facility clean and in good repair.

CONTINUED ON LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

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 5

Control Number 11-AS-20250418093426

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: 09/18/2025

NARRATIVE

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Investigation revealed the following:

Allegation: Staff did not provide responsible party with a refund.

On 04/25/25 LPA Watson interviewed Staff#1-Staff#4 (S1-S4). Of those interviewed 4 out of 4 staff denied the above allegation. On 09/18/2025 LPA Watson interviewed Residents #1-Resident #7 (R1-R7). Of those interviewed, 7 out of 7 residents denied the allegation. LPA Watson requested and obtained from the Executive Director evidence of a personal check that the responsible, party owed the facility $2604.19 and later paid their balance in full. Based on the information gathered and records reviewed there is insufficient evidence to support the stated allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20250418093426

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: 09/18/2025

NARRATIVE

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Allegation: Staff did not communicate with responsible, party regarding resident's care.

On 04/25/25 LPA Watson interviewed Staff#1-Staff#4 (S1-S4). Of those interviewed 4 out of 4 staff denied the above allegation. On 09/18/2025 LPA Watson interviewed Residents #1-Resident #7 (R1-R7). Of those interviewed, 7 out of 7 residents denied the allegation. LPA Watson obtained a notice of increase dared (01/25/2024) the informed the responsible party of increase in care in the amount of $5900.00. Based on the information gathered and records reviewed there is insufficient evidence to support the stated allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20250418093426

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: 09/18/2025

NARRATIVE

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Allegation: Staff charged resident for services not rendered.

On 04/25/25 LPA Watson interviewed Staff#1-Staff#4 (S1-S4). Of those interviewed 4 out of 4 staff denied the above allegation. On 09/18/2025 LPA Watson interviewed Residents #1-Resident #7 (R1-R7). Of those interviewed, 7 out of 7 residents denied the allegation. LPA Watson requested, obtained and reviewed the Resident Ledger and is showed the correct charges for services rendered. Based on the information gathered and records reviewed there is insufficient evidence to support the stated allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff did not provide responsible party with resident's facility records.

On 04/25/25 LPA Watson interviewed Staff#1- Staff#4 (S1-S4). Of those interviewed 4 out of 4 staff denied the above allegation. On 09/18/2025 LPA Watson interviewed Residents #1-Resident #7 (R1-R7). Of those interviewed, 7 out of 7 residents denied the allegation. LPA Watson reviewed a copy of the records that were given to the resident. Based on the information gathered and records reviewed there is insufficient evidence to support the stated allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20250418093426

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: 09/18/2025

NARRATIVE

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Allegation: Staff did not provide resident with a reappraisal.

On 04/25/25 LPA Watson interviewed Staff#1- Staff#4 (S1-S4). Of those interviewed 4 out of 4 staff denied the above allegation. On 09/18/2025 LPA Watson interviewed Residents #1- Resident #7 (R1-R7). Of those interviewed, 7 out of 7 residents denied the allegation. LPA Watson reviewed and obtained a Notice of Increase that the resident received on 01/25/24. Based on the information gathered and records reviewed there is insufficient evidence to support the stated allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with the Executive Director, Nestor Mendez and a copy of this report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC9099 (FAS) - (06/04)

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