<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601661
Report Date: 08/28/2024
Date Signed: 08/28/2024 09:43:09 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/07/2024 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240807164428
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
UNANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Executive Director Khatera BahadoryTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not respond to residents call in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/28/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA met with Executive Director Khatera Bahadory and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA Cloyd delivered findings.

On 08/15/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Executive Director Khatera Bahadory and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA reviewed facility records and interviewed 10 residents and 8 staff which included the Executive Director, Memory Care Director, Resident Care Coordinator, Lead Care Provider/MedTech, and (4) Care Providers. Due to insufficient time, the above allegation needs further investigation. A copy of this report was reviewed and left with the Executive Director Khatera Bahadory.
Continue to LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 11-AS-20240807164428
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VISTA
FACILITY NUMBER: 198601661
VISIT DATE: 08/28/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The investigation revealed the following: Regarding the allegation "Staff does not respond to residents call in a timely manner," it is being alleged that the facility is severely understaffed, especially after 9:00 PM, and staff did not respond to Resident #1’s (R1) pull cord on 08/07/24. It is being alleged that on 07/13/24, R1 had to wait two hours for staff to respond to the pull cord. It is also being alleged that visitors cannot enter at night because no one is at the front desk.

Record review reveals the following: The 08/07/24 SMARTcare report does not indicate that R1 needed assistance in the evening. The 07/13/24 SMARTcare report was not archived; therefore, unavailable. LPA observed pull cords in residents’ room and pendants around some residents’ neck. Four out six resident interviews indicated that night staff responds in a timely manner. Three resident interviews indicated that night staff care hasn’t been needed. One resident was unavailable. One resident interview indicated that he/she will call the after-hours number if staff did not respond to the pull cord or pendant. Record review revealed that the facility has a contact list that includes a number for concierge, assisted living after hours, and memory care after hours. Interview with the Executive Director indicated that the contact list is provided to families, and they may call the after-hour number for entry since doors lock at 8:00 PM. Seven out of eight staff interviews, including the Executive Director, indicated that staff responds immediately or within 5 – 10 minutes. Interview with the Executive Director indicated that night staff conduct at least three rounds: at the beginning of their shift, around 1:00 AM, and around 4:30 AM or 5:00 AM. The Executive Director also indicated that from 10:30 PM – 5:45 AM, there is a MedTech, three care providers for assisted living, a floater and two to three care providers for memory care who can respond to residents’ calls in a timely manner. Regarding the allegation “Staff does not respond to residents call in a timely manner," based on record reviews, observation, 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 did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiency was cited for this allegation.

An exit interview was conducted and a copy of this report was provided to the Executive Director Khatera 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2