198601661-11-20-2025-11-AS-SCIS-DU22GQ-20260512172329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 11/20/2025
Date Signed: 11/20/2025 05:07:52 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

PUBLIC

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: 68	DATE:	11/20/2025
		UNANNOUNCED	TIME BEGAN:	08:23 AM
MET WITH:	BUSINESS OFFICE DIRECTOR - MARIA DEHOYA BELLOMO		TIME COMPLETED:	04:55 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 11/20/2025 at approximately 08:20 AM, Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit to deliver findings regarding the above allegation(s). LPA met with the Business Office Director Maria Dehoya Bellomo and explained the purpose of the visit. LPA was granted entry to the facility.

The investigation consisted of the following:

On 04/23/2025 between 10:39AM – 02:00PM the department requested, obtained, and reviewed the following records: LIC500 Personnel Report, Resident Roster, Chase check in the amount of $2,604.19 dated 08/06/2025, Residence and Service Agreement, Notice of Care Increase dated 01/11/2024, Resident Charges/Payment Ledger (covering 01/01/2024 to 02/01/2024 and 04/16/2025), Kaiser Permanente Hospice Discharge Note/Care dated 03/15/2024 to 03/19/2024, Special Incident Report (SIR) dated 03/22/2025. A tour of the facility was conducted, and the facility was observed to be clean and in good repair.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

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 6

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: 11/20/2025

NARRATIVE

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Investigation revealed the following:

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

This complaint is alleging that staff charged (R8) for services not rendered and that the facility owes between $10,000.00 and $20,000.00 to (R8’s) responsible party. On 04/23/2025 between 10:39AM – 02:00PM the department interviewed Staff #1 -#4 (S1–S4). Out of those interviewed, 4 out of 4 staff denied the allegation. On 09/18/2025 between 09:10AM – 04:50PM the department interviewed Residents #1 - #7 (R1–R7). On 09/18/2025 between 09:10AM – 04:50PM an attempt was made to interview Resident #8 (R8), but R8 could not be interviewed because according to the Special Incident Report (SIR) Death Report dated 03/22/2025, provided by Ivy Park at Playa Vista, obtained and reviewed by the department, R8 was admitted to Cedars Sanai Hospital Marina Del Rey on 03/14/2025 at 08:40PM and passed away on 03/21/2025 at approximately 05:30AM. Out of those interviewed, 7 out of 8 residents denied the allegation. On 11/20/2025 between 08:20AM – 03:30PM the department interviewed the Administrator (A1) and asked the Administrator if R8 was due and provided a refund? A1 responded yes and stated they were provided with a prorated credit of $3,270.30 per their Admission Agreement because R8 passed away. A review of records obtained from the facility showed that $3,270.30 was credited to his billing and is reflected on the Resident Charges/Payment Ledger documentation covering 01/01/2024 to 04/16/2025. The department reviewed the regulation on service charges contained in the Admission Agreement in Section 9 which states that the resident R8 shall remain liable for the monthly fees until the apartment is vacated, and all property is removed from Ivy Park at Playa Vista and that a prorated refund shall be paid to you or your Responsible Party for any prorated unused portion of your final monthly fee payment. The department has determined that R8 received credit for a prorated amount according to the Resident Agreement and was not owed any refund.

CONTINUED ON LIC9099 -C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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: 11/20/2025

NARRATIVE

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

This complaint is alleging that staff failed to communicate with the Responsible Party regarding R8’s care. On 04/23/2025 between 10:39AM – 02:00PM, the department interviewed Staff #1- #4 (S1–S4). Out of those interviewed, 4 out of 4 staff denied the allegation. On 09/18/2025 between 09:10AM – 04:50PM the department interviewed Residents #1-#7 (R1–R7). On 09/18/2025 between 09:10AM – 04:50PM. On 09/18/2025 between 09:10AM – 04:50PM an attempt was made to interview Resident #8 (R8), but R8 could not be interviewed because according to the Special Incident Report (SIR) Death Report dated 03/22/2025, provided by Ivy Park at Playa Vista, obtained and reviewed by the department, R8 was admitted to Cedars Sanai Hospital Marina Del Rey on 03/14/2025 at 08:40PM and passed away on 03/21/2025 at approximately 05:30AM. Out of those interviewed, 7 out of 8 residents denied the allegation. On 11/20/2025 the department conducted an interview with the Administrator (A1). A1 said that the Responsible Party and or family members were contacted whenever there were concerns, or changes in conditions. On 09/18/2025 between 09:10AM – 04:50PM the department obtained and reviewed a Notice of Increase in Monthly Rate dated 11/11/2024 and it addressed to R8’s Responsible Party. The department has determined based on interviews; records obtained and reviewed that R8’s Responsible Party received communication regarding R8’s care.
Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated.

Allegation: Staff charged a resident for services not rendered.

CONTINUED ON LIC9099 - C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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: 11/20/2025

NARRATIVE

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This complaint is alleging that staff charged R8 for services that were not provided. On 04/23/2025 between10:39AM – 02:00PM the department interviewed Staff #1- #4 (S1–S4). Out of those interviewed, 4 out of 4 staff denied the allegation. On 09/18/2025 between 09:10AM – 04:50PM an attempt was made to interview Resident #8 (R8), but R8 could not be interviewed because according to the Special Incident Report (SIR) Death Report dated 03/22/2025, provided by Ivy Park at Playa Vista, obtained and reviewed by the department, R8 was admitted to Cedars Sanai Hospital Marina Del Rey on 03/14/2025 at 08:40PM and passed away on 03/21/2025 at approximately 05:30AM.Out of those interviewed, 7 out of 8 residents denied the allegation. On 11/20/2025 the department conducted an interview with the Administrator (A1). A1 stated that R8’s Responsible Party has provided documents that showed R8’s services rendered. The department obtained and reviewed the Resident Ledger, which reflected accurate charges for services rendered. The Resident Charges/Payment Ledger showed rental payments from 12/01/2024 through 09/18/2025. R8’s family was not charged for services not received. The family was notified of rate increases via a letter dated 11/11/2024, effective 01/26/2025. All services billed to R8 were confirmed as rendered. The department has determined that R8’s Responsible Party was provided with documents showing R8’s services were rendered.
Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated.

CONTINUED ON LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

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: 11/20/2025

NARRATIVE

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

This complaint is alleging that staff failed to provide the Responsible Party with R8’s facility records. On 04/23/2025 between10:39AM – 02:00PM the department interviewed Staff #1 -#4 (S1–S4). Out of those interviewed, 4 out of 4 staff denied the allegation. On 09/18/2025 between 09:10AM – 04:50PM an attempt was made to interview Resident #8 (R8), but R8 could not be interviewed because according to the Special Incident Report (SIR) Death Report dated 03/22/2025, provided by Ivy Park at Playa Vista, obtained and reviewed by the department, R8 was admitted to Cedars Sanai Hospital Marina Del Rey on 03/14/2025 at 08:40PM and passed away on 03/21/2025 at approximately 05:30AM. Out of those interviewed, 7 out of 8 residents denied the allegation. On 11/20/2025 the department conducted an interview with the Administrator (A1). A1 was asked if staff provided R8’s Responsible Party with R8’s facility records. A1 stated that the facilities usual protocol is records are sent or delivered to the residents Responsible Party via email or written correspondence according to how it is set up by the Responsible Party. The department reviewed the Notice of Increase in Monthly Rate and the Reassessment document, both of which were addressed to R8’s Responsible Party. Interviews with 4 staff and 7 residents confirmed that facility records were provided by the facility to them when requested within a week to 24 hours. The department has determined that the staff did provide R8’s Responsible Party with facility records when requested.
Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 6

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: 11/20/2025

NARRATIVE

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Allegation: Staff did not provide residents with a reappraisal.

This complaint is alleging that staff failed to provide R8 with a reappraisal. On 04/23/2025 between10:39AM – 02:00PM the department interviewed Staff #1- #4 (S1–S4). Out of those interviewed, 4 out of 4 staff denied the allegation. On 09/18/2025, between 09:10AM – 04:50PM the department interviewed Residents #1- #7 (R1–R7).. On 09/18/2025 between 09:10AM – 04:50PM an attempt was made to interview Resident #8 (R8), but R8 could not be interviewed because according to the Special Incident Report (SIR) Death Report dated 03/22/2025, provided by Ivy Park at Playa Vista, obtained and reviewed by the department, R8 was admitted to Cedars Sanai Hospital Marina Del Rey on 03/14/2025 at 08:40PM and passed away on 03/21/2025 at approximately 05:30AM. Out of those interviewed, 7 out of 8 residents denied the allegation. On 11/20/2025 the department conducted an interview with the Administrator (A1). A1 stated that a Service Plan was and is supplied when requested to all residents and their Responsible Parties within one or two days or request which is our customary practice. A1 also stated that the assessment is reviewed and or sent to the Responsible Party depending on their preference of receiving the assessment.
The department obtained and reviewed a Notice of Increase dated 01/25/2024 and a Reassessment Letter addressed to the residents P.O.A, stated that a reassessment and review of the service plan had been completed on 01/22/2024. The letter indicated a change in care from 236 points to 295 points, with a new monthly cost of $5,900.00, effective as of the reassessment date. The change was to be reflected in the next billing statement. A new assessment for R8 was conducted on 02/03/2025 and a return from the hospital resulted in a $2,436 reduction in fees. R8’s care costs decreased from $4,410 to $3,024 on 02/02/2025, and R8’s family was involved in the reassessment process. A review or records requested and obtained from the facility showed that the facility provided R8 with a reappraisal. The department has determined that staff provided R8’s Responsible Party with a reappraisal.
Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated.
An exit interview was conducted with the Administrator, Dina Davis and a copy of this report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025

LIC9099 (FAS) - (06/04)

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