198601661-5-15-2024-11-AS-SCIS-D5XVKS-20240605163045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:14:20 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
10/31/2023 and conducted by Evaluator Elvira Gonzalez

COMPLAINT CONTROL NUMBER: 11-AS-20231031114420

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: 76	DATE:	05/15/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sabrina Tucker		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not give authorized representative a copy of the care plan.
Due to staff negligence, resident was found unconscious on floor for an unknown time.
Staff did not respond to authorized representatives calls.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 05/15/24, Licensing Program Analyst (LPA) Elvira Gonzalez conducted a subsequent complaint visit to address the following allegations. LPA met with Sabrina Tucker, Executive Director, and Andrea Weathersby, Business Office Director, and explained the purpose of the visit.

The investigation consisted of the following: On 11/06/23, LPA Montoya toured the facility with Andrea Weathersby, Business Office Director. LPA Montoya interviewed six on-duty staff (S1-S6) and four residents (R1-R4). LPA requested and obtained copies of Staff roster, Resident roster, and one resident's (R1) service records (Admission Agreement, Physician's Reports and Appraisals/Needs and Services Plans). LPA also requested other pertinent records from Andrea Weathersby. On 05/15/24 LPA Gonzalez interviewed five residents (R5-R9). LPA requested and obtained, Progress notes for the month of August 2023, and the Care Plan for R1.

Continued on LIC9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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 3

Control Number 11-AS-20231031114420

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: 05/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following:

Allegation: Staff did not give authorized representative a copy of the care plan.
It is alleged that staff did not provide authorized representative with a copy of the care plan and that authorized representative was told that there was never a care plan written for the resident. R1 was admitted to this facility on 03/18/23. LPA interviewed Sabrina Tucker, Executive Director and she stated that they go over the Care Plan with the authorized representatives when going over and signing the Residency Agreement. Records review revealed that on 11/3/23 a copy of the Care Plan and Residency Agreement was provided to resident #1 family member (R1 FM1) via email from Executive Director Sabrina Tucker. On 05/15/24 LPA spoke with FM1 to verify information and confirmed the electronic email address for FM1.

Based on records review, and interviews with staff, LPA did not find sufficient evidence to support the above allegation.

Allegation: Due to staff negligence, resident was found unconscious on floor for an unknown time.

It is alleged that on 08/23/23 the reporting party got a call from the staff at the facility saying that they found resident on the floor unresponsive, and they did not know how long she had been on the floor. Reporting party was concerned that no staff checked on the resident to verify if she was okay. Records review revealed that on 08/28/23 as a medication technician was entering the resident’s apartment suite, she found the resident on the floor. 911 paramedics were called, and the resident was transported to the hospital. On 11/06/23, LPA Montoya conducted interviews with six staff members (S1-S6) and four residents (R1-R4). On 05/15/24 LPA Gonzalez conducted interviews with Executive Director, Sabrina Tucker and four residents (R5-R8) Based on interviews conducted, five out of six staff stated that they did not know of any incident where a resident was found unconscious on the floor due to staff negligence, and six out of eight residents stated that they haven’t heard of a resident falling and staff not tending to them when they call for assistance.
Based on records review, and interviews, LPA did not find sufficient evidence to support the above allegation.

Continued on LIC9099

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20231031114420

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: 05/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff did not respond to authorized representative’s calls.

It is alleged that on 10/30/23, reporting party called the resident and noticed the resident was having trouble using the phone. Reporting party then called the main office five times to ask staff to check on the resident. Reporting party stated that they did not get a call back until 7 PM after they had been calling the facility all afternoon. On 11/06/23, LPA Montoya conducted interviews with six staff members (S1-S6) and four residents (R1-R4). On 05/15/24 LPA Gonzalez conducted interviews with Executive Director, Sabrina Tucker and four residents (R5-R8) Based on interviews conducted, six out of six staff stated that they did not know of a family member or an authorized representatives calls not being returned. Staff stated that they try and return family members calls as soon as possible. Eight out of eight residents interviewed stated that they haven’t heard of their family members calls not being returned and that staff do their best at keeping up with the residents.

Based on records review, and interviews, LPA did not find sufficient evidence to support the above allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Exit interview was conducted and a copy of the report was provided to Sabrina Tucker, Executive Director.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3