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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601661
Report Date: 09/20/2023
Date Signed: 10/12/2023 02:42:04 PM


Document Has Been Signed on 10/12/2023 02:42 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: 88DATE:
09/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Barbara TabbTIME COMPLETED:
04:45 PM
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On 09/20/2023 at 8:14 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Barbara Tabb, Director of Memory Care. The facility is licensed to serve 102 non-ambulatory of which 18 may be bedridden. Hospice waiver for 20 residents. New management CO, Oakmont Management Group LLC. Effective 7/1/2023. An estimate of eighty-eight (88) residents were present during this inspection. The Annual Licensing Fees are not current.

The facility has 6 floors which consist of resident bedrooms, bathrooms, living room, activity room, dining room, and kitchen. Floors 3 and 4 are used for memory care.

Mrs. Tabb accompanied LPA inside and outside the facility during this inspection. The facility is in the process of having a new elevator installed. Current elevator vendor is using parking spaces near walkway, a small patio area, and indoor room to store items.

10 staff records were reviewed, but incomplete. However, all staff were cleared and associated to the facility and had current first aid certificates.

10 resident records were reviewed, but incomplete. Due to time constraints an Annual Continuation visit will be conducted.

A copy of this report, LIC 859 (Review of Staff Records), LIC 859-C (Review of Staff Records Continued), LIC 858 (Resident Records Review), and LIC 858-C (Resident Records Review Continued) was discussed and left with Business Office Director, Andrea Weathersby.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
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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