198601661-3-21-2025-11-AS-UCOL-DFFPVV-20250405113947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 03/21/2025
Date Signed: 03/21/2025 04:05:51 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
03/07/2025 and conducted by Evaluator Regina Cloyd

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250307105640

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:	102	CENSUS: 76	DATE:	03/21/2025
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Dina Davis		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Staff did not provide written notice of rate increase due to level of care.
Staff do not communicate with resident's authorized representative regarding care in a timely manner.

INVESTIGATION FINDINGS:

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The investigation consisted of the following:

On 03/14/2025, Licensing Program Analysts (LPAs) Regina Cloyd and Jose Anguiano conducted a complaint investigation at the above facility to address the following allegations. LPA met with Regional Operations Specialist Dina Davis and explained the purpose of the visit. LPAs conducted resident and staff interviews and reviewed facility and resident records. On 03/21/25, LPA Cloyd conducted a subsequent visit and met with Dina Davis. LPA conducted resident and staff interviews and review facility and resident records.

Allegation:
Regarding the allegation "Staff did not provide written notice of rate increase due to level of care,” it is being alleged that Resident #1’s (R1) level of care cost increased prior to R1’s October 2024 and December 2024 assessments.
CONTINUED LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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-20250307105640

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: 03/21/2025

NARRATIVE

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Record review of the Residency Agreement revealed if the resident's condition changes so that the previously assessed Service Level is no longer appropriate, the Community will reevaluate the Resident's needs to determine which Level is appropriate and notify the Resident/Responsible Party of such reevaluation. The fee charged will be based upon the Service Level provided. Should the Resident wish to decrease the services received, prior approval from the Community is required. Changes in services provided will be reflected in a revised service plan. Record review of R1’s Care Fee Notice (10/31/25) revealed effective 01/01/25 care fees will increase 6%. S1 indicated that legacy residents, those living at the facility under the previous Licensee, received this flat rate increase. Record review of R1’s Charges/Payment Ledger revealed R1’s care fee remained consistent from 01/01/24 – 12/01/24. There is a rate increase as of 01/01/25. Four out of four staff interviews (S1, S3, S4, S6) indicated notices are provided before there’s an increase of care cost.

Regarding the allegation “Staff did not provide written notice of rate increase due to level of care, based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiency was cited for this allegation.

Allegation:

Regarding the allegation "Staff do not communicate with resident's authorized representative regarding care in a timely manner,” it is being alleged Resident #1 (R1) fell in February 2025 and staff did not contact the primary point of contact (Witness #1/W1). It is alleged that the staff hasn’t called W1 for previous incidents either. Record review of Residency Agreement revealed in the event that the Resident requires emergency services or experiences a significant change in condition, the Community will attempt to contact the Responsible Party or other individual designated by the Resident, within twelve (12) hours. The Resident is responsible for ensuring that the Community has current telephone numbers for the individuals to be notified. Record review of R1’s face sheet reveals W1 as the responsible party.

Record review of R1’s Face Sheet lists W1 as the responsible party. Five out of five staff interviews (S2 – S6) indicated that the authorized representative is contacted when incidents occur. Five out of nine resident interviews indicated staff communicates with authorized representatives.

CONTINUE TO LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250307105640

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: 03/21/2025

NARRATIVE

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Regarding the allegation “Staff do not communicate with resident's authorized representative regarding care in a timely manner,” based on record reviews and interviews the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiency was cited for this allegation.

An exit interview was conducted and a copy of this report was provided to the Regional Operations Specialist Dina Davis.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC9099 (FAS) - (06/04)

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