198601662-2-16-2024-28-AS-LHIS-D55N7X-20240510101324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601662
Report Date: 02/16/2024
Date Signed: 02/16/2024 05:02:39 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2024 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240213083741

FACILITY NAME:	IVY PARK AT SAN MARINO		FACILITY NUMBER:	198601662
ADMINISTRATOR:	KIMBERLY SANCHEZ		FACILITY TYPE:	740
ADDRESS:	83332 HUNTINGON DR		TELEPHONE:	(626) 292-7800
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	74	CENSUS:	DATE:	02/16/2024
		UNANNOUNCED	TIME BEGAN:	12:06 PM
MET WITH:	Kimberly Sanchez, Executive Director		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Staff did not respond to a resident's alert button in a timely manner or at all.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Executive Director Kimberly Sanchez.

The investigation consisted of: A physical plant tour of the common areas of the facility, with special focus on the Memory Care Unit signal, pendant, and pager system. Resident (R1's) file was reviewed. The following documents were obtained: Face Sheet, Admission Agreement, Physician's Report, Individual Service Plan (ISP), Home Health Agency Care Notes, Shower Schedule, Lifeline Fall Detection Pendant Instructions, LIC 500 Personnel Report, and resident roster. Staff (S1- S6), residents (R1-R3), and family (F1-F2) were interviewed.

***Narrative summary continues next page.***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240213083741

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT SAN MARINO	FACILITY NUMBER: 198601662
	VISIT DATE: 02/16/2024

NARRATIVE

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Allegation: Staff did not respond to a resident's alert button in a timely manner or at all. It is alleged that Memory Care staff have a slow response or no response to call button calls made during evening/nighttime hours. It was reported that resident (R1) has pushed the pendant for assistance and has waited for 2 hours and other times no staff respond to the call. A total of 6 staff were interviewed, of which five (5) staff confirmed that the facility has had issues with the pagers signal and resetting. According to staff, there have been problems with the pagers for at least six months. In the last 1-2 weeks there have been more issues with the pagers because the resetting feature is not working, or the residents click the pendant and the pager does not receive the signal. Resident (R1) stated that in the last week there have been numerous times the pendant button was pressed and there was no response at all. Two (2) family members were interviewed and they stated there have been issues with staff response times after calls for assistance. Maintenance Director stated that the pendant is supposed to be pushed three times in order for a signal to be received in the pager, and that some residents do not operate the pendant properly. However, per review of the Instructions for Use of the pendant it does not state that. LPA tested pendants and room pull-string buttons in Memory Care rooms, and staff did not receive the signal on their pagers. It was discovered that some of the staff pagers used in the Memory Care unit are faulty because a signal is not received on the pager. Later in the day, Executive Director, Maintenance Director, and LPA tested the signal system, pendant system, and pull string and it was determined that the problem is the pager system. There is sufficient evidence to corroborate the allegation.

Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D.

An exit interview was conducted with Executive Director Kimberly Sanchez. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240213083741

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT SAN MARINO	FACILITY NUMBER: 198601662
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/17/2024 Section Cited CCR 87303(i)(1)(C)	1 2 3 4 5 6 7	Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: Identify the specific resident living unit.	1 2 3 4 5 6 7	Executive Director agreed to: 1. Submit a written POC stating how the deficiency will be corrected by tomorrow 2. Proof of staff in-service due 2/20/24 3. Proof that the entire building's signal system, pager, and pendants were tested and are operational is due 2/20/24.
	8 9 10 11 12 13 14	Based on physical plant observations during the visit, some of the facility pagers in the Memory Care unit are faulty failing to receive a signal and failing to reset after a call is answered. Pendants, pull-strings were tested. This poses an immediate health and safety risk.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC9099 (FAS) - (06/04)

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