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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601661
Report Date: 08/28/2024
Date Signed: 08/28/2024 09:47:28 AM


Document Has Been Signed on 08/28/2024 09:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VISTAFACILITY NUMBER:
198601661
ADMINISTRATOR:TUCKER, SABRINAFACILITY TYPE:
740
ADDRESS:5555 PLAYA VISTA DRTELEPHONE:
(310) 437-7178
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY:102CENSUS: 76DATE:
08/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Executive Director Khatera BahadoryTIME COMPLETED:
10:00 AM
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On 08/15/24, Licensing Program Analyst (LPA) Regina Cloyd was conducting a complaint (11-AS-20240807164428) visit and informed Executive Director and Resident Care Coordinator that Community Care Licensing has not received any June, July, nor August unusual incident reports from the facility. During interviews, LPA learned that the documents were not faxed to the (424) 544-1016 number.

A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

A copy of this report and technical violation was provided to the Executive DirectorKhatera Bahadory.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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