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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601661
Report Date: 09/05/2024
Date Signed: 09/05/2024 04:41:01 PM


Document Has Been Signed on 09/05/2024 04:41 PM - 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:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Executive Director Khatera BahadoryTIME COMPLETED:
04:45 PM
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On 09/05/24, Licensing Program Analysts (LPA) Regina Cloyd and Hollie Enriquez conducted an unannounced required – annual inspection and met with the Executive Director Khatera Bahadory.

The facility is licensed to serve 102 non-ambulatory of which 18 may be bedridden. Hospice waiver for 20 residents. Delayed egress on the third and fourth floor. The facility has 6 floors which consist of resident bedrooms, bathrooms, living room, activity room, dining room, and kitchen. Floors 3 and 4 are used for memory care.



The Administrator accompanied LPAs inside the facility during this inspection. LPA Enriquez inspected the first and second floor. LPA Cloyd inspected the third, fourth, fifth, and sixth floor. Common areas were clean and clear of hazards. Doorways were free of obstructions.

LPA Enriquez toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet.

Staff and resident records were reviewed. Emergency disaster and infection control plan was reviewed. Due to insufficient time, an annual continuation is needed.

No deficiencies are being cited at this time.

An exit interview was conducted and a copy of this report was discussed and left with Executive Director Khatera Bahadory.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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