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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602549
Report Date: 10/02/2023
Date Signed: 10/02/2023 04:27:24 PM


Document Has Been Signed on 10/02/2023 04:27 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:IVY PARK AT PALOS VERDESFACILITY NUMBER:
198602549
ADMINISTRATOR:KELLEY KOULFACILITY TYPE:
740
ADDRESS:25535 HAWTHORNE BLVDTELEPHONE:
(310) 377-7425
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:115CENSUS: 77DATE:
10/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Kelley KoulTIME COMPLETED:
04:00 PM
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On 10/02/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Case Management visit regarding an Incident Report for R1 having a series of falls resulting in a fracture. LPA Gibbs met with Executive Director, Kelley Koul, and explained the purpose of today's visit.

The Regional Office received a copy of the Incident Report on 09/26/23. The Incident Report stated that on 09/20/23 and 09/21/23, R1 had episodes of falls. R1 was assessed by hospice nurse. Hospice ordered Lidocaine patch and increased the dosage of their Tramadol regarding pain management. Case Manager Nurse assessed R1 on 09/22/23. STAT Xray ordered by case manager hospice nurse. On 09/23/23 POA confirmed to send out R1 to hospital due to pain, swelling on the right knee and procedure of x-ray was not conducted by TMMC hospice.


R1 was admitted to the hospital on 09/23/23, diagnosed with a fractured right femur. Resident underwent surgery on 09/26/23. R1 returned to the facility on 09/29/23, with a one-on-one caregiver provided.

During today's visit LPA Gibbs and Administrator toured the facility. LPA Gibbs received documents pertinent to the Incident Report. LPA received copies of the following documents for R1:


-Resident Information Sheet
-Admission Agreement
-Physician's Report
-Preplacement Appraisal Information
-Assessment and Service Plan
-Progress Notes
-Incident Reports
-Healthcare Provider Communication from Hospice provider.

No deficiencies were observed or cited during today's visit.
An exit interview was conducted with Executive Director, Kelley Koul, and a copy of this report was provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
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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