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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 06/06/2025
Date Signed: 06/06/2025 12:12:28 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
05/06/2025 and conducted by Evaluator Regina Cloyd
COMPLAINT CONTROL NUMBER: 11-AS-20250506152933
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: 73DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Executive Director Nestor MendezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility does not employ adequate staffing to meet the needs of the residents.
Residents are left in soiled diapers for extended periods of time.
INVESTIGATION FINDINGS:
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On 05/14/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegations. On 06/06/25, LPA conducted a subsequent visit to deliver findings. LPA met with Executive Director Nestor Mendez and the purpose of the visit was explained.

Investigation consisted of the following: On 05/14/25, LPA obtained Personnel Roster, Register of Residents, April 2, 2025 – April 4, 2025 and May 1, 2025 – May 16, 2025 2:00 PM – 6:00 AM Call Logs, April 27, 2025 – May 17, 2025 Assisted Living Work Schedule, and interviewed Residents #1-7 and Staff #1 - 6. On 05/15/25 and 05/23/25, LPA received residents’ records and April 27, 2025 – May 17, 2025 Memory Care Work Schedule. On 05/29/25, LPA Jose Anguiano interviewed witnesses over the telephone. On 06/04/25, LPA Cloyd interviewed staff #5, 7-8, and 10 over the telephone.

Continue to LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
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-20250506152933
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: 06/06/2025
NARRATIVE
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Investigation revealed the following:

Regarding the allegation, “Facility does not employ adequate staffing to meet the needs of the residents,” it is alleged that there were only two staff members on floors #1, 2, 5 and 6 for the evening shift and the overnight shift and residents are not receiving showers. Record review of Assisted Living Care Schedule (05/04/25 – 05/10/25) revealed four to six staff members, including supervisors, worked Sunday through Wednesday evening (2pm – 10pm) and two to three staff members worked overnight (10:00pm – 6:00am). Seven staff members, including supervisors, were scheduled Thursday evening and three staff members were scheduled for the overnight shift. Four to six staff members, including supervisors, were scheduled for Friday and Saturday evening and two staff members were scheduled for the overnight shifts. Interview with S1 indicated that there are 42 residents in assisted living, management assist whenever there is a call off, and the memory care staff are also available to help in assisted living. Thus, the facility can have eight caregivers at one time. Four out of four staff interviews (S5, S7, S8, S10) indicated that memory care will support in assisted living when called. Three out of four staff interviews (S1-S2, S6 – S7) indicated there is enough staff to meet the needs of the residents. Three out of three staff interviews (S3-S5) indicated the facility is short staff due to call offs, but they are able to meet residents’ needs. Record review of the call logs revealed 21 resident calls were made on Friday, 5/9 from 10:00 PM – 6:00 AM. Two to four calls were made per hour. Record review of Assisted Living Care Schedule revealed two staff members worked. Both staff members indicated they were able to meet the needs of the residents. Record review of the call logs revealed 14 calls were made on Saturday, 5/10 from 10:00 PM – 6:00 AM. One to three calls were made per hour. Record review of Assisted Living Care Schedule revealed two staff members worked. Both staff members indicated they were able to meet the needs of the residents. Two out of three resident interviews (R1, R3, R8) indicated there is enough staff. Three out of three resident interviews (R4, R6, R7) indicated there isn’t enough staff but they are able to respond to care needs. One of out of two witnesses denied the allegation and the third witness declined to be interviewed due to no concerns.

Regarding the allegation, Facility does not employ adequate staffing to meet the needs of the residents, based on record review 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(s) did or did not occur, therefore the allegation is unsubstantiated.

Continue to LIC9099-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250506152933
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: 06/06/2025
NARRATIVE
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Allegation:
Regarding the allegation, “Residents are left in soiled diapers for extended periods of time,” it is being alleged that some residents are left in soiled diaper for extended periods of time. Record review of register of residents revealed there are eleven residents who require incontinence care. Six out of seven staff interviews (S1 – S7) indicated residents are not left soiled for an extended period. Interview with Executive Director and Health Services Director indicated there hasn’t been any resident nor family complaints. Three out of five resident interviews (R2 - R4, R6, R8) indicated they are not left soiled for an extended period. R1 and R5 indicated no incontinent assistance is needed. One of out of two witnesses denied the allegation and the third witness declined to be interviewed due to no concerns.

Regarding the allegation, “Residents are left in soiled diapers for extended periods of time,” based on record review 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(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies issued.

A copy of this report was reviewed and provided to the Executive Director Nestor Mendez.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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