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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601662
Report Date: 05/28/2024
Date Signed: 05/28/2024 04:44:38 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
07/24/2023 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230724140131
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: 56DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Kimberly Sanchez, Executive DirectorTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Resident sustained a fall causing injuries due to lack of staff supervision.
Facility door poses a risk to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations. The investigation was conducted by DSS/CCLD Investigations Branch (IB) Investigator Juan Lozano. The purpose of the visit was explained to Executive Director Kimberly Sanchez.

The investigation consisted of: On 7/25/2023, LPA Galarza conducted a health and safety check that included a physical plant inspection of the common areas of the facility and resident (R1's) room. File review was conducted and documents pertaining to resident (R1) were reviewed/obtained including; Face Sheet, Admission Agreement, Physician's Report, Health Assessment, Individual Service Plan (ISP), Progress Notes (May 2023- present), Initial Assessment, Medication Administration Records (MARs - May 2023- present), incident reports, hospital/medical documents, Post Fall Evaluation, LIC 500 Personnel Report, and resident roster. During the course of the investigation, Investigator Lozano obtained additional pertinent documents and interviewed staff. Photograph evidence was obtained. NOTE: Resident (R1) fell on 3/24/2023, and an incident report was not submitted to CCL or provided to DSS staff.

***Narrative summary continues next page.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
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 6
Control Number 28-AS-20230724140131
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: 05/28/2024
NARRATIVE
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Allegation: Resident sustained a fall causing injuries due to lack of staff supervision. It is alleged that resident (R1) had a serious fall on March 24, 2023 that caused a head injury and broken nose. Based on DSS Investigator Juan Lozano's investigation, the findings indicate the resident had an additional total six (6) falls; 3 in August 2023, 1 in October 2023, and 2 in November 2023 after the March 2023 fall, that consisted of facial injuries, head injury, and skin tears. Resident (R1) moved into the facility in November 2022, and staff interviews revealed that the resident was identified as a fall risk and Service Plan was updated after each fall. Most of the falls took place when the resident was alone and unassisted. Staff stated that multiple efforts were made by staff to prevent falls. However, due to cognitive impairment, R1 was unable to use the call pendant to alert staff when they required escorting assistance and/or other care. According to information obtained, facility staff discussed with R1's authorized representative relocation of the resident into the facility's Memory Care Unit but family refused to transition R1 into the Memory Care Unit and the resident remained living in the Assisted Living floor of the facility. Document review revealed that R1's Physician's Report states the resident has Dementia and lists R1’s mental condition as confused/disoriented and with motor impairment/paralysis and. The 8/7/2023 Service Plan stated that R1 is at high risk for falling and had signage in the room to remind the resident to call for assistance. According to record review and interviews conducted, R1 needed a higher level of care because the resident’s health was observed to be declining. Based on the totality of the circumstances, facility staff should have reasonably known and taken appropriate measures in ensuring resident (R1) received appropriate care and supervision, as recommended by MD in the Physician’s Report (3/27/23). The resident should have been relocated into the Memory Care Unit or transferred to a facility that could provide adequate care. Photo evidence of injuries was obtained. There is sufficient evidence to corroborate the allegation.


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

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20230724140131
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: 05/28/2024
NARRATIVE
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Allegation: Facility door poses a risk to residents in care. The complaint alleges the disrepair in resident (R1's) room door caused the resident to fall on March 2023. On 7/25/2023, a physical plant inspection of the room was completed by LPA in the presence of Executive Director. Based on observation, the resident's room door is a fire door that did not meet safety standards because during the visit the door was tested four (4) times and two (2) out of the four (4) times the door did not close completely. A door stopper was observed at the bottom of the door. Note: Photographs were taken of the door. Per Executive Director, R1's family had requested the door remain propped open in order for resident to be observed closer. Based on observation, it appeared the door was not functioning properly. Therefore, the effectiveness of the door was compromised. Fire doors should always remain closed. The facility resident room doors do not have a device that releases and allows the doors to close upon fire alarm or smoke detection. Instead facility staff used plastic wedges at the bottom of the fire door to keep the door propped open. Based on observation, resident (R1's) door close and latch feature was not working properly because the door did not completely close.

Based on observation, record review, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are 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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20230724140131
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: 05/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/28/2024
Section Cited
CCR
87464(f)(1)
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Basic Services. Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement was not met evidenced by:
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Executive Director agreed to:
1. Submit a written Plan of Correction explaining facility procedures regarding higher level of care relocation to Memory Care Unit when applicable.
2. Provide in-service training proof that addresses regulation 87464 and change in condition.
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Based on record review and interviews conducted, the findings indicate that Dementia resident (R1) sustained a head injury and broke their nose on 3/24/2023, but facility failed to take appropriate care and supervision measures, this posed an immediate health and safety risk to the resident.
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Type B
06/04/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Executive Director stated the door was fixed on LPA inspected the door today and was observed to be working properly.

*Citation is cleared.
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Based on observation, during the physical plant inspection dated 7/25/2023, R1's room door is a fire door that was not working properly, and was also being left opened with a plastic wedge; therefore the effectiveness of the door was compromised which poses a potential health and safety risks to persons in care.
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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: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
07/24/2023 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230724140131

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: 56DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Kimberly Sanchez, Executive DirectorTIME COMPLETED:
04:40 PM
ALLEGATION(S):
1
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3
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Facility staff do not ensure a safe environment for resident(s) in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations. The investigation was conducted by DSS/CCLD Investigations Branch (IB) Investigator Juan Lozano. The purpose of the visit was explained to Executive Director Kimberly Sanchez.

The investigation consisted of: On 7/25/2023, LPA Galarza conducted a health and safety check that included a physical plant inspection of the common areas of the facility and resident (R1's) room. File review was conducted and documents pertaining to resident (R1) were reviewed/obtained including; Face Sheet, Admission Agreement, Physician's Report, Health Assessment, Individual Service Plan (ISP), Progress Notes (May 2023- present), Initial Assessment, Medication Administration Records (MARs - May 2023- present), incident reports, hospital/medical documents, Post Fall Evaluation, LIC 500 Personnel Report, and resident roster. During the course of the investigation, Investigator Lozano obtained additional pertinent documents and interviewed staff. Photograph evidence was obtained. NOTE: Resident (R1) fell on 3/24/2023, and an incident report was not submitted to CCL or provided to DSS staff.

***Narrative summary continues next page.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20230724140131
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: 05/28/2024
NARRATIVE
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Allegation: Facility staff do not ensure a safe environment for resident(s) in care. The concern pertains to facility staff failing to provide a safe environment and escort assistance to resident (R1) to and from meals forcing the resident to navigate on their own, which was a contributing factor to the seven (7) falls resident (R1) sustained during 2023. Per record review, fall interventions were in place and being followed. Resident (R1's) authorized representative was notified of challenges with resident (R1) not pressing the pendant to call for assistance or escorting. Most of the falls took place because the resident did not remember to press the pendant to call for assistance when ambulating in the room. Staff stated that R1 used a cane to get around the facility and received Physical Therapy to help with mobility. On 7/25/2023, LPA observed the resident eating in the dining room. The resident had a plastic brace on the lower right foot area, and a 4 prong cane was observed next to the resident. During the visits, no health and safety issues were observed. Record review revealed R1's Service Plan was assessed and updated after each fall, and the resident was provided reminders to use a cane, pendant, pull cord, or call light. All staff interviewed denied the allegation by stating that resident (R1) received extra attention as frequent room checks, and that staff spent longer periods of time with R1 compared to other residents in the Assisted Living rooms. There is insufficient evidence to corroborate the allegation.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6