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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 04/22/2025
Date Signed: 04/22/2025 11:45:53 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, 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
03/25/2025 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20250325134443
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: 75DATE:
04/22/2025
UNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Nestor MendezTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff increased resident's rent without the required written notice.
INVESTIGATION FINDINGS:
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On 04/22/25, at 11:21 am, Licensing Program Analyst (LPA) Antonine Richard met with Executive Director Nestor Mendez and explained that the purpose of the visit was to deliver findings.
The investigation consisted of the following:

On 04/02/2025, Licensing Program Analyst (LPA) Antonine Richard initiated a complaint investigation at the above facility to address the following allegation. LPA met with Regional Operations Specialist Dina Davis and explained the purpose of the visit. LPA conducted resident and staff interviews and reviewed and obtained facility and resident records. Notice of Increase in the Monthly rate, Resident ledger, Assessment & Service Plan, and Resident Services Agreement for R1.

CONTINUED LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
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 3
Control Number 11-AS-20250325134443
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: 04/22/2025
NARRATIVE
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Allegation: Facility staff increased residents’ rent without the required written notice.

It is being alleged that the facility did not provide the required written notice before increasing Resident #1’s (R1) monthly care level before R1’s return from a temporary stay in rehab in 2024. On 04/02/2025, LPA Richard Record review of the Residency Agreement revealed that on 11/01/2023, the facility sent a Notice of Increase in Monthly Rate to all the residents. On 04/02/2025, LPA Richard interviewed the Regional Operation Specialist (ROS) Dina Davis, who stated that the changes in services provided will be reflected in a revised service plan to the Resident/Responsible Party of such revaluation, the facility would not increase a resident monthly care level fee without inform the resident responsible party through emails, mails, or given a copy to the residents. Record review of the resident #1 (R1’s) Notice of Increase in Monthly Rate (dated 11/01/23) revealed that effective 01/01/24, care fees will increase by 10%, due to the increase in year-over-year costs. And the care fees, if any, will remain the same at this time unless the care needs of the resident change. A record review of R1’s Charges/Payment Ledger revealed R1’s monthly care fee remained consistent from 01/01/2024 to 09/01/2024, until the day R1 moved out of the facility on 09/01/2024. LPA records review of R1’s Charges/Payment Ledger indicated R1 received credit for being in rehab (dated 05/21/24 to 05/31/24), and after R1 came back to the facility.

Continued LIC9099-C

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

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250325134443
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: 04/22/2025
NARRATIVE
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On 04/02/25, LPA interviewed five (5) residents (R2-R6), 5 out of 5 stated that their family member talked to them about receiving notice of the increased monthly rate, and they also stated that they understand that if the resident needed more care, the rate would go up. On 04/02/25, LPA interviewed four (4) staff (S1-S4), 3 out of 4 stated that they knew about the facility sending out a Notice of Increase in Monthly Apartment Home rent to all the residents/responsible parties.

Regarding the allegation, the Facility staff increased residents’ rent without the required written notice. Based on record reviews and interviews, LPA 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 deficiencies were cited. Exit interviewed conducted. A copy of the report was provided to the Executive Director Nestor Mendez.

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

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3