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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601662
Report Date: 10/26/2023
Date Signed: 10/26/2023 05:00:11 PM


Document Has Been Signed on 10/26/2023 05:00 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:IVY PARK AT SAN MARINOFACILITY NUMBER:
198601662
ADMINISTRATOR:KIMBERLY SANCHEZFACILITY TYPE:
740
ADDRESS:83332 HUNTINGON DRTELEPHONE:
(626) 292-7800
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:74CENSUS: 44DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Kimberly Sanchez, Executive Director TIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Executive Director Kimberly Sanchez. There are currently 44 elderly residents 60 years and older residing in the facility.

The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.


Operational Requirements:
  • An Infection Control Plan has been added to the Plan of Operation.
  • The facility has a Dementia Waiver in place and an approved Hospice Waiver for 12 residents.
  • A fire clearance for 74 non-ambulatory residents; of which 10 may be bedridden is in place.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 5/1/2024.
  • No Surety bond is in place. Facility does not handle resident monies.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/26/2023
NARRATIVE
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Physical Plant/Environment Safety:
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. There is a water fountain that is inaccessible to memory care residents. Cleaning supplies and toxic substances are inaccessible to residents.

  • The facility is 2-story building consisting of a Memory Care unit "Reminiscence", 52 resident rooms, 2 activity rooms, 2 dining rooms, kitchen, 2 tv rooms, library, Bistro room, hair salon, administration offices, laundry rooms, storage areas, 2nd floor terrace area, 1st and 2nd floor stairways evacuation chairs, courtyard patio area, and parking garage.
  • On 5/21/2023, an annual fire inspection was conducted. The sprinkler system, alarms, fire connections, and kitchen hood system were inspected. The facility has fully charged fire extinguishers.
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.
  • Beds in rooms 127, 203, 207, 234, 245, and 251 did not have mattress pads. Citation was issued.

Staffing:
  • A total of 65 staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expired 8/5/2023 . Administrator provided proof that recertification training documents were submitted to CCL Recertification unit. Recertification process is pending.
  • Staff have criminal background clearance and training.
  • Seven (7) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was observed. One (1) staff (S3) did not have a current 1st Aid/CPR card on file. Citation was issued.


***See next page.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/26/2023
NARRATIVE
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Resident Records/Incident Reports:
  • A total of seven (7) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, Individual Service Plans, and medication records.
  • RCFE complaint poster and Personal rights were observed posted.

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • An activity calendar is posted in the entrance area.
  • The facility has a Resident Council.

Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
  • Physician orders for modified diets are on file. A diet type report was observed in the kitchen.
  • Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:
  • Seven (7) centrally stored resident medications were reviewed; containing a 30-day supply of medications.
  • Medical and dental transportation is provided.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E was reviewed. Evacuation chair at each stairway is in place.
  • Records of resident Appraisal and Needs services plans are part of Emergency training.

*****See next page.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/26/2023
NARRATIVE
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Residents with Special Health Needs:
  • Eight (8) residents are receiving hospice services. Ten (10) residents receive home health services.
  • Postural support physician orders are on file.
  • Half bed rails for mobility assistance were observed in some resident rooms.
  • Individual Service Plans and Appraisals are on file.
  • No residents have prohibited health conditions.


Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Executive Director Kimberly Sanchez. A copy of the report and appeal rights will be emailed due to printing problems.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/26/2023 05:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
Personal Accommodations and Services
Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that beds in rooms 127, 203, 207, 234, 245, and 251 did not have mattress pads; which poses a potential health and safety risk.
POC Due Date: 11/09/2023
Plan of Correction
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Submit picture proof and a written statement of how the deficiency was corrected.
Type B
Section Cited
CCR
87411(c)(1)
PERSONNEL REQUIREMENTS - GENERAL
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff (S3 ) did not have current 1st Aid/CPR training on file; which poses/posed a potential health, safety or personal rights risk to persons in care.

POC Due Date: 11/09/2023
Plan of Correction
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Submit a copy of S3's 1st Aid/CPR training card.
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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5