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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 06/27/2024
Date Signed: 06/27/2024 02:02:58 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
06/20/2024 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240620120707
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: DATE:
06/27/2024
UNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Andrea WeathersbyTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff are charging resident for services not rendered.
INVESTIGATION FINDINGS:
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On 06/27/24, at 11:00am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Andrea Weathersby, Administrator. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegation mentioned above.

The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1). LPA attempted several times to interview R1 but R1 is no longer a resident at the facility and the current address for the resident is unknown. LPA received the following documents from the facility: Resident Roster (Dated: 05/23/2024), Staff Roster (Dated:06/27/2024 ), Physicians Report (Dated: 11/06/2023), Admission Agreement (Dated: 11/11/2023 & 03/21/2024), Resident Charges/Payments Ledger for 11/13/2023-06/27/2024 (Dated: 06/27/2024), Thirty Day Notice (Dated: 04/23/2024), Final Account Statement (Dated: 05/31/2024), and 1Heart Caregiver Services Agreement (Dated:02/01/2024) for R1.

Report continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
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 2
Control Number 11-AS-20240620120707
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: 06/27/2024
NARRATIVE
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The investigation revealed the following: Allegation #1- Staff are charging resident for services not rendered.

The details of the complaint alleged that R1, as of two months ago, is no longer at the facility. However, the facility is charging for services not provided for R1 as R1 was in the hospital for two months. On 06/27/24, from 11:00am-1:00pm, LPA interviewed staff (S1) regarding the allegation. R1 could not be interviewed because R1 is no longer at the facility and no new contact information was given. 1 of 1 staff denied the allegation that the Staff are charging resident for services not rendered. S1 stated that R1 was in the hospital for several months and returned on 03/22/2024 where R1 was placed in the Memory Care unit as opposed to Assisted Living where the resident was living before R1 went into the hospital. S1 stated that the resident lived at the facility until 04/23/2024 when a thirty-day notice was given by the family member that they were taking R1 home. S1 advised that they needed to give a thirty-day notice, as stated in the admission agreement. LPA reviewed the admission agreement (Dated: 03/21/2024) that states if You move out without providing thirty (30) days’ notice, You will be responsible for the amount of your monthly fee through the date You move plus one full month’s fees.

However, S1 stated that the resident is not being charged for services not rendered, when in fact the resident is due a refund for $7,157.42. After the facility prorated fees and the months the resident was in the hospital the residents account had a credit due. LPA reviewed the Final Account Statement (Dated: 05/31/2024) as well as the Resident Charges/Payments Ledger for 11/13/2023-06/27/2024 (Dated: 06/27/2024) and found that a refund was due. S1 stated that the facility has the check for the resident and has tried to get in contact with the family member that has Power of Attorney, but they have not returned their calls. S1 stated that the check is here for the resident, they did not want to mail it as the address may have changed. They will continue to call the family member until the matter is resolved and the check has been issued.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are charging resident for services not rendered. 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, therefore the allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted with Andrea Weathersby, Administrator, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (707) 849-2315
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC9099 (FAS) - (06/04)
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