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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 03/14/2025
Date Signed: 03/21/2025 10:04:41 AM

Unsubstantiated


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
01/23/2025 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250123092616
FACILITY NAME:IVY PARK AT PLAYA VISTAFACILITY NUMBER:
198601661
ADMINISTRATOR:KHATERA BAHADORYFACILITY TYPE:
740
ADDRESS:5555 PLAYA VISTA DRTELEPHONE:
(310) 437-7178
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY:102CENSUS: 76DATE:
03/14/2025
UNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Regional Operations Specialist Dina DavisTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff caused an injury to a resident while in care.
Staff used drugs on the facility grounds.
Staff did follow injection procedures for the residents.
Staff have inadequate record keeping for the residents.
Staff mishandled the residents medications.
Staff did not seek timely medical attention for a resident.
Staff did not provide a safe environment to residents.
Staff did not follow infection control requirements.
INVESTIGATION FINDINGS:
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The original LIC9099 and LIC9099Cs dated 03/14/2025, are being amended. The revised LIC9099 and LIC9099Cs dated 03/21/2025.The amendment does not change the findings of this investigation. On 03/21/25 LPA Richard conducted a subsequential visit and met with the new Executive Director Dina Davis, and interviewed Marilyn Butler.The amendment does not change the findings of this investigation. On 03/14/25, Licensing Program Analyst (PLA) Regina Cloyd, conducted a subsequent unannounced complaint visit to the facility listed above. The investigation consisted of the following: On 01/24/25, LPA Richard obtained a copy of the following documents. Resident roster, staff roster, Medication Administration Record (MAR) from 10/07/24 to 01/22/25, for resident #1-2 Physician Report #1-2. Admission Agreement. Resident Safety and Fire Disaster. Shift Report for Resident (dated 01/01/25 to 01/21/25. Heath Screening Report for six staff. Facility Disciplinary Action Notice. On 01/24/25, between 10:20 am to 12:15 pm, LPA conducted interviews with residents #1-8 (R1-R8), and between 12:00 pm to 2:30 pm LPA conducted interviews with staff #1-6 (S1-S6). The investigation revealed the following:
Allegation #1: Staff caused an injury to a resident while in care. It is being alleged that staff is using malfunctioning and broken equipment to move the resident causing the resident to sustain a laceration on the right leg. Continue to LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
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-20250123092616
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: 03/14/2025
NARRATIVE
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On 01/24/25 between 10:20 am- and 12:15 pm, LPA Richard interviewed one resident #1 (R1) who denied the allegation and stated it was superficial scratches on the right leg that only needed a band-aid. On 01/24/25 between 12:00 pm and 2:30 pm, LPA interviewed six staff #1-6 (S1-S6) 6 out of 6 denied the allegation. They stated that they all received training on how to use the Hoyer lift before using it. The record review of the facility Shift Report (dated 01/19/25 to 01/20/25) indicated that R1 was seen by the facility nurse for a superficial scratch on the right leg, and first aid and a patch were administered. On 01/24/25, LPA did not observe any visible laceration on R1's right leg.

Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated.

Allegation #2: Staff use drugs on the facility grounds.

It is being alleged that staff used drugs on work premises. On, 01/24/25, between 10:20 am, and 12:00 pm LPA interviewed eight residents #1-8 (R1-R8) 7 out of 8 stated that they had never witnessed any of the staff using drugs on the ground of the facility. On 01/24/25, between 12:00 pm and 2:30 P.m., LPA Richard interviewed six staff #1-6 (S1-S6) 6 out of 6 denied the allegation and stated that the facility has rules on using drugs or disorderly conducted inside or outside the facility premises. All the staff stated that the facility has a town hall each month with staff and residents to make sure the residents and staff can report to management anything they see outside the facility premises.

Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated.

Allegation #3: Staff did not follow injection procedures for the residents.

It is being alleged that medication technicians instructed other staff to falsely chart insulin injections as being given on time when they had not, and the staff would administer it later. On 01/24/25, at 12: 00 p.m. LPA Richard interviewed the staff (S6) Health Services Director who denied the allegation and stated that the facility only has two residents who are in insulin injections. Continue to LIC9099-C.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20250123092616
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: 03/14/2025
NARRATIVE
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The facility does assist them with the injections. S6 stated that when the other resident went to dialysis the family administered the injection on those days Monday, Wednesday, and Friday morning. On, 03/21/25, between 9:20 am, and 9:30 am, LPA interviewed one residents #8 (R8) R8 denied the allegation and stated that the nurse assisted R8 with the injection and R8 wanted to do it self, but the nurse refused. LPA record review of MARs dated 10/07/24 to 01/22/25 revealed no false entries and also indicated the date and time when the injections were administered. On 01/24/25, LPA observed the facility computer generate documents showing when the insulin injection was given on time in the morning, and evening but charging late entry.

Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated.

Allegation #4: Staff did not inadequate record keeping for the residents.

It is alleged that staff has illegal chart charting and false documentation of residents' reports. On 01/24/25 LPA Richard interviewed six staff #1-6 (S1-S6) 6 out of 6 denied the allegation and stated the facility keeps adequate records on all the care provided to residents in care. LPA interviewed Staff #4 (S4) Executive Director who stated that accurate records are kept for all residents including all medical records, incident reports, visitor logs, emails, hospice records, hospital records, and notes of all residents who refuse medications. S4 also stated that all the family members can obtain and review all records of the resident. S4 also stated all facility staff take continuous training in record keeping. On 01/24/25 LPA Richard's record review of the facility record keeping of the MAR (dated 10/07/24 to 01/22/25) revealed the facility staff signed and dated all the residents who took or refused medications that day. On 01/24/25, LPA Richard reviewed the Quick Mar System that showed all the previous records keeping dated 09/10/2024 to 01/22/25 of all residents were adequate.

Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated.

Continue to LIC9099-C.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20250123092616
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: 03/14/2025
NARRATIVE
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Allegation #5: Staff mishandled the resident's medications.

It is alleged that medication had not been passed to the resident and the staff charted false information to the Quick Mar system and claimed the medication was given at a specific time. On 01/24/25, LPA Richard interviewed staff #6 (S6) Health Service Director who denied the allegation. S4 also stated that the Medical Administration Record (MAR) is kept for every resident in care who takes medications at the facility. The MARs are signed at the time medications are administered. The facility passed out the medication using the locked cart, and staff #3 (S3) MedTech would go to where the residents were at the time to administer the medications. On 01/24/25 LPA Richard's record review of the MAR (dated 10/07/24 to 01/22/25) revealed the facility staff signed and dated all the residents who took or refused medications that day. On 01/24/25, LPA Richard reviewed the Quick Mar System that showed all the previous medications dated 09/10/2024 to 01/22/25 of all residents were signed and given on time.

Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated.

Allegation #6: Staff did not seek timely medical attention for a resident.

It is alleged that due to a lack of first aid supplies staff apply band-aid instead of providing proper care. On 01/24/25, between 12:00 pm and 2:30 pm, LPA Richard interviewed six staff #1-6 (S1-S6), 6 out of 6 who stated that the facility does assist residents on time. No resident has complained or informed them that they did not receive assistance in a timely manner. On 01/24/25 between 10:20 and 12:00 pm, LPA Richard interviewed eight residents #1-8 (R1-R8) 8 out of 8 denied the allegation and stated the staff was always quick to assist them as soon as they asked for assistance, and they were happy with the staff response time. On 01/24/25, LPA reviewed the S6 Shift notes dated 01/19/25 to 01/21/25, which showed R1 received proper medical attention on time. During the tour of the facility on, 01/24/25, LPA Richard observed the facility has numerous fire extinguishers and several first aid kit supplies on all floors. Based on interviews, observation, and record review LPA Richard found no evidence to support the allegation.

Continue to LIC-9099C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20250123092616
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: 03/14/2025
NARRATIVE
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Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated.

Allegation #7: Staff did not provide a safe environment to the resident.

It is alleged that staff are having inappropriate behavior, arguing in a resident's room and the executive director had to intervene. On 01/24/25, between 10:20 and 12:00 pm, LPA interviewed eight residents #1-8 (R1-R8) 8 out of 8 denied the allegation. On 01/24/25 between 12:00 P.m. to 2:30 P.m., LPA interviewed six staff #1-6 (S1-S6) 6 out of 6 denied the allegation and stated that the facility has rules for the staff not to yell or speak too loud inside the resident rooms. The facility has a town hall with the resident so they can let the facility staff know what is on their mind, and what the staff are doing right or wrong. Based on interviews LPA Richard found no evidence to support the allegation mentioned above.

Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated.

Allegation #8: Staff did not follow infection control requirements.

It is alleged that medication that have been left out from the AM shift needs to be refrigerated and discarded to prevent contamination and infecting the residents. On, 01/24/25, between 10:20 am, and 12:00 pm, LPA interviewed eight residents #1-8 (R1-R8) 8 out of 8 stated that the staff does follow infection control requirements. They also stated the staff provided them with gloves, hand sanitizers, and masks. On 01/24/25, between 12:00 pm, and 2:30 pm, LPA interviewed six staff #1-6 (S1-S6) 6 out of 6 denied the allegation and stated they have continuous training on infection control. They also stated that the facility has multiple refrigerators to store any medications that need to be refrigerated. On 01/24/25 LPA Reviewed the facility Infection Control Plan. LPA observed the facility, which has a room full of hand sanitizers, gloves, masks, and all the mandated requirements posted on the wall of every floor at the facility.

Continue to LIC9099-C.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20250123092616
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: 03/14/2025
NARRATIVE
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Based on the interviews, observations, and record review (s) LPA Richard found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur therefore the allegations are unsubstantiated.

No deficiencies were cited.

An exit interview was conducted and a copy of this report was provided to the Executive Director Dina Davis.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6