198601661-5-11-2026-11-AS-SCIS-DU22GP-20260512172328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 05/11/2026
Date Signed: 05/11/2026 02:35:38 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: 81	DATE:	05/11/2026
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	REGIONAL OPERATION SPECIALIST - DINA DAVIS		TIME COMPLETED:	02:20 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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**This report supersedes the previous reports dated 9/18/2025 and 11/20/2025, but does not change the findings**

On 11/20/2025 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.

The investigation consisted of the following:

CONTINUED ON LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

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: 05/11/2026

NARRATIVE

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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 for R8, Notice of Care Increase dated 01/11/2024, Resident Charges/Payment Ledger (covering 01/01/2024 to 02/01/2024 and 04/16/2025) for R8, Kaiser Permanente Hospice Discharge Note/Care dated 03/15/2024 to 03/19/2024 for R8, 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. On 04/23/2025 the department interviewed Staff #1–#4 (S1–S4). On 11/20/2025 the department spoke with administrator 1 Dina Davis (A1). On 09/18/2025 between 09:10AM – 04:50PM the department interviewed Residents #1–#7 (R1–R7). An attempt to interview Resident #8 (R8) was made, but R8 could not be interviewed because they passed away on 03/14/2025. On 7/7/2025, the facility went through a change of ownership.

Investigation revealed the following:

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

It is alleged that staff charged resident (R8) for services not rendered and that the facility owes between $10,000.00 and $20,000.00 to the resident and 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). R8 could not be interviewed because they passed away on 03/14/2025. Out of those interviewed, 7 out of 7 residents interviewed 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 as R8 passed away on 03/14/2025. A review of records obtained from the facility showed that $3,270.30 was credited to R8’s billing and is reflected on the Resident Charges/Payment Ledger covering 01/01/2024 to 04/16/2025.

CONTINUED ON LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

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: 05/11/2026

NARRATIVE

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The department reviewed the Admission Agreement, and Section 9, states that “the resident 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 the resident or Responsible Party for any prorated unused portion of the final monthly fee payment. The department reviewed R8’s Needs and Services plan dated 03/23/2024, which showed that R8 was receiving almost total assistance with Activities of Daily Living (ADL’s} and PRN medication.

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 did not communicate with responsible, party regarding resident’s care.

It is alleged 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). R8 could not be interviewed because they passed away on 03/14/2025. Out of those interviewed, 7 out of 7 residents denied the allegation. On 11/20/2025 the department conducted an interview with the Administrator (A1). A1 said that Responsible Party and/or family members are contacted whenever there are concerns or changes in a resident’s conditions or care.

The department obtained charting notes from the facility dated 01/26/2025-03/22/2025 that notate communication with family, as well as letters from the facility to the family dated 01/21/2026 regarding level of care change.

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: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

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: 05/11/2026

NARRATIVE

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Allegation: Staff charged a resident for services not rendered.

It is being alleged that staff charged Resident #8 (R8) for services that were not provided.

On 04/23/2025, between 10:39 AM and 2:00 PM, the Department interviewed Staff #1–#4 (S1–S4) and Residents #1–#7 (R1–R7). R8 was not available for interview as they passed away on 03/14/2025. Out of those interviewed, 4 out of 4 staff and 7 out of 7 residents denied the allegation.
On 11/20/2025, the Department conducted an interview with the Administrator (A1). A1 stated that R8’s Responsible Party provided documents indicating that services billed to R8 were rendered. The Department obtained and reviewed R8’s Resident Ledger, which reflected accurate charges for the services listed on R8’s needs and services plan. The Department also reviewed R8’s Needs and Services Plan dated (03/23/2024) and R8’s facility Hospice Care Plan. The documentation shows that R8 received almost total care for activities of daily living.

Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred, 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 did not provide the Responsible Party with residents’ facility records.

It is being alleged that staff failed to provide R8’s Responsible Party with R8’s hospice records. On 04/23/2025, between 10:39 AM and 2:00 PM, the Department interviewed Staff #1–#4 (S1–S4). Of those interviewed, 4 out of 4 staff denied the allegation. On 04/23/2025, between 10:39 AM and 2:00 PM, the Department interviewed Residents #1–#7. R8 was not available for interview as they passed away on 03/14/2025. Out of those interviewed, 7 out of 7 residents denied the allegation.

CONTINUED ON LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC9099 (FAS) - (06/04)

Page: 4 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: 05/11/2026

NARRATIVE

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On 11/20/2025, the Department conducted an interview with the Administrator (A1). A1 stated that the facility’s standard protocol is to send or deliver requested records to the Responsible Party via email and verified that R8 was receiving hospice services from Kaiser Hospice agency. The department requested verification of records given to the family. On 7/7/2025 the facility went through a change in ownership, and although A1 tried, they could not verify records requested from previous owner. The facility was able to provide department some hospice notes and plan of care, Per the facilities hospice plan of care, they only maintain certain records at the facility, all others are kept by hospice agency.

The department reviewed facility records and found the following: On 3/27/2024 the department was notified via fax of the initiation of hospice services for R8. The department reviewed Hospice Plan of Care for R8 dated 3/19/2024, which details the name of the hospice agency, primary contacts for the hospice agency, an outline of service to be provided by hospice to the resident, an outline of training that hospice will be providing facility staff, brief outlines of licensee vs hospice duties, communication and record keeping. The department also reviewed hospice agency care notes, which just noted recommendations from hospice to facility about residents continued care.

Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred, 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 did not provide residents with a reappraisal.

This complaint alleges that staff failed to provide Resident #8 (R8) with a reappraisal. On 04/23/2025, between 10:39 AM and 2:00 PM, the Department interviewed Staff #1–#4 (S1–S4). Out of those interviewed 4 out of 4 staff interviewed denied the allegation. On 09/18/2025, between 9:10 AM and 4:50 PM, the Department conducted interviews with Residents #1–#7. Out of those interviewed 7 out of 7 residents interviewed denied the allegation.

CONTINUED ON LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

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: 05/11/2026

NARRATIVE

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On 11/20/2025, the Department conducted an interview with the Administrator (A1). A1 stated that a Needs and Services Plan or reappraisal is provided to residents and their Responsible Parties upon request, typically within one to two days, which is the facility’s customary practice. A1 further stated that assessments are reviewed and/or sent to the Responsible Party depending on their preferred method of receiving the information. On 04/23/2025, between 10:39 AM and 2:00 PM, the Department reviewed a letter dated 01/25/2024 addressed to R8 stating that a reappraisal and review of the service plan had been completed on 01/22/2024.

The letter informed R8 that the facility wished to review the reappraisal and service plan together and offered options for doing so in person, by phone, via email, or in writing. The letter also stated that once reviewed, the service plan needed to be signed and returned to the facility for their record keeping. The department further reviewed facility records and found a new assessment for R8 was completed on 02/03/2025, following R8’s return from the hospital.

Based on the information gathered and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have occurred, 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 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: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC9099 (FAS) - (06/04)

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