198601661-3-15-2024-11-AS-MVAO-D3RVUD-20240327164433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 03/15/2024
Date Signed: 03/15/2024 03:50:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/12/2024 and conducted by Evaluator Regina Cloyd

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240312090230

FACILITY NAME:	IVY PARK AT PLAYA VISTA		FACILITY NUMBER:	198601661
ADMINISTRATOR:	TUCKER, SABRINA		FACILITY TYPE:	740
ADDRESS:	5555 PLAYA VISTA DR		TELEPHONE:	(310) 437-7178
CITY:	PLAYA VISTA	STATE: CA	ZIP CODE:	90094
CAPACITY:	102	CENSUS: 78	DATE:	03/15/2024
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Administrator Sabrina Tucker		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Staff is refusing to accept resident back to the faciltiy.

INVESTIGATION FINDINGS:

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On 03/15/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation. LPA met with Administrator Sabrina Tucker and explained the purpose of the visit.

The investigation consisted of the following: During today’s investigation, LPA interviewed 8 staff members which included the Administrator, Business Office Director, Regional Health Services Specialist, (2) Lead Care Manager and (3) Care Providers, and the LPA reviewed records.

Continue to LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240312090230

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/15/2024

NARRATIVE

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The investigation revealed the following: Regarding the allegation "Staff is refusing to accept resident back to the facility," it is being alleged that Resident #1 (R1) cannot return to the facility. Record review reveals the following: R1 went to the hospital on 01/25/24. On 02/16/24, the Medical Doctor provided a notice stating, R1 “is cleared for discharge... and [R1] has not exhibited behaviors harmful to self or others over the past 2 weeks”. The facility has the capacity to provide care and supervision for residents during the time of notification from the hospital. Regarding the allegation “Staff is refusing to accept resident back to the facility," based on interviews and record reviews, the preponderance of evidence has been met therefore the allegation is Substantiated.

Deficiencies were issued. An exit interview was conducted and plans of correction developed. A copy of this report and appeals rights was reviewed and left with Administrator Sabrina Tucker.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240312090230

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/29/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	In addition to the rights listed in Section 87468.1,... residents... shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered... to meet their needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee will make arrangements to receive R1 back to the facility by the POC due date and provide evidence of R1's return to regina.cloyd@dss.ca.gov
	8 9 10 11 12 13 14	Licensee did not provide R1 with care, supervision, and services that met R1 needs. On 02/16/24, the facility was informed that R1 was ready to be discharged and did not receive the resident which posed a potential personal rights risk to the resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC9099 (FAS) - (06/04)

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