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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601662
Report Date: 11/08/2024
Date Signed: 11/08/2024 05:02:38 PM

Document Has Been Signed on 11/08/2024 05:02 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/
DIRECTOR:		KIMBERLY SANCHEZFACILITY TYPE:
740
ADDRESS:8332 HUNTINGTON DRIVETELEPHONE:
(626) 292-7800
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 0TOTAL ENROLLED CHILDREN: 0CENSUS: 61DATE:
11/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:20 PM
MET WITH:Kimberly Sanchez, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted a Case Management- Deficiencies visit due to record review findings while investigating complaint control #: 28-AS-20240628144003. The purpose of the visit was explained to Executive Director Kimberly Sanchez.

The facility failed to report to Community Care Licensing the initial fall that occurred on 6/21/2024 pertaining to resident (R1), in which the resident fell off of their wheelchair while being pushed by caregiver staff.

An incident report was faxed on 6/27/2024, but the report omitted details about the cause of the swelling, which was the leg being caught on the wheelchair and subsequent fall. The resident was discharged from the hospital back to the facility with a right leg fracture on 6/27/24, the day staff faxed the incident report. The report did not include the hospital diagnosis of right leg femur fracture.

Per 87211(a)(B) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.... Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.

NOTE: The same citation was issued on 5/28/2024 regarding non-reporting of a serious resident fall that resulted in head injuries and a broken nose to another resident.

Per Title 22 California Code of Regulation a citation and repeat violation Civil Penalty is being assessed.

Exit interview held with Executive Director Kimberly Sanchez. A copy of the report and appeal rights were provided.
Lisa HicksTELEPHONE: (323) 981-3972
Noemi GalarzaTELEPHONE: (323) 981-3974
DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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Document Has Been Signed on 11/08/2024 05:02 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: 11/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/13/2024
Section Cited
CCR
87211(a)(B)

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Reporting Requirements. Each licensee shall furnish... A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.... Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
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Executive Director agreed to provide a written plan of correction that includes:
1. Caregiver in-service training in reg. 87211
2. Copy of facility reporting procedures, and staff protocols after resident injuries.
3. Submit a copy of R1's 6/21/24 incident report.
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This requirement was not met evidenced by: Based on record review, on 6/21/24, R1 sustained serious injuries resulting in femoral fractures, after falling while staff pushed the resident's wheelchair. The facility did not submit an incident report to CCL, which poses a potential health and safety risk. NOTE: It is a repeat citation within the last 12 months.
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NOTE: Civil penalty in the amount of $250.00 is being assessed.

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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.
Lisa HicksTELEPHONE: (323) 981-3972
Noemi GalarzaTELEPHONE: (323) 981-3974

DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024

LIC809 (FAS) - (06/04)
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