198602549-1-5-2024-11-AS-WGIS-CZ82JC-20240105162607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602549
Report Date: 01/05/2024
Date Signed: 01/05/2024 04:26:18 PM

Document Has Been Signed on 01/05/2024 04:26 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 VERDES		FACILITY NUMBER:	198602549
ADMINISTRATOR:	KELLEY KOUL		FACILITY TYPE:	740
ADDRESS:	25535 HAWTHORNE BLVD		TELEPHONE:	(310) 377-7425
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	115	CENSUS: 65	DATE:	01/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:23 AM
MET WITH:	Kelley Koul		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 01/05/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Administrator, Kelley Koul, and explained the purpose of today’s visit. The facility is licensed to operate for 115 non-ambulatory elderly residents ages 60 and above, of which 50 and be bedridden and approved hospice for 20. There are currently 65 residents residing in the facility. Twenty (20) of the residents are bedridden, and there are three (3) residents on hospice. Structure/Physical Plant The facility is a five-story structure located in a commercial neighborhood. The ground floor is the parking and entrance, the first and second floors are Assisted Living, the third floor is Memory Care for residents and the fourth floor is Memory Care. There is a total of 37 Assisted Living units and 40 Memory Care units. During the tour, LPA did not observe any bodies of water on the premises. Gates around the Resident outside area are egressed and an alarm will be set off if the gates are opened. Outside sitting area was observed to have chairs, tables and umbrellas. All outside walkways were observed to be clean, clear, and free of obstructions and hazards. Living Units LPA inspected 8 living units and observed them to clean and in good repair. Upon moving in, residents have the option to furnish the living unit with their belongings or they can use facility provided furniture which includes a bed, dresser, nightstand, and chair. LPA observed ample storage space for resident’s personal belongings. Bathrooms LPA inspected all common area bathrooms and private bathrooms in units visited by LPA. All bathrooms were observed to be clean and free of mold or mildew. All showers had secured safety handrails, nonskid material, and shower chairs. The water temperature measured between 108.2 and 112.8-degrees Fahrenheit. LPA observed ample towels and hygiene products in residents living units. Common Rooms LPA inspected all common areas and found them to be clean and appropriately furnished during time of visit. LPA observed multiple areas for residents to read, watch T.V., or participate in activities. All rooms were observed with ample seating to accommodate all residents. LPA observed all hallways and walkways to be clean, clear, and free of obstructions, and hazards. All rooms were observed with ample lighting. The facility was maintained at a comfortable temperature.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 VERDES	FACILITY NUMBER: 198602549
	VISIT DATE: 01/05/2024

NARRATIVE

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Kitchen LPA inspected the commercial kitchen and observed it to be clean and sanitary. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. LPA observed all food properly stored, labeled, and dated. LPA observed an ample supply of cookware, dining ware, and cutleries in good repair.
Files & Interviews LPA reviewed seven (7) resident files and observed they had the required documents. During interviews with residents, they stated they were happy with the service they receive at the facility. LPA reviewed six (6) staff files and found they had the required documents, certification, and training. LPA interviewed eight (8) staff and eight out of eight were able to answer questions regarding policy, procedure, treatment, and rights of residents. LPA reviewed the Resident Council meeting notes for the past three (3) months. LPA observed all required documents posted within the facility.
Medications LPA observed all centrally stored medication secured in a medication cart, in the Med Room, and are inaccessible to residents. Each floor has a locked med cart. LPA reviewed the medications and Medication Administration Record (MAR) for 7 residents. Seven (7) out of seven (7) resident’s MARs and medication are consistent with properly documented records.
Safety LPA observed smoke and carbon monoxide detectors were operable. LPA observed multiple fire extinguisher throughout the facility that were last serviced on 12/27/23. The last emergency drill was conducted on 12/26/23. The last Fire Prevention Inspection was conducted by the Torrance Fire Department on 08/15/23. LPA reviewed and received a copy of the facilities Emergency Disaster Plan last updated on 07/01/23. LPA observed fire doors throughout the facility, which close automatically if a fire alarm goes off. LPA inspected the First Aid Kit and observed it had the required items and a manual. LPA reviewed and received a copy of the facilities Liability Insurance through Acord and is valid till 05/01/24. LPA reviewed and received a copy of the generator test logs conducted twice a month. LPA reviewed the service log of the generator that is checked three (3) times a year by Direct Supply Tels.
Infection Control During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a minimum 30-day supply of Personal Protective Equipment (PPE) available. All mandated infection control posters were observed posted.
During today's visit LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Kelley Koul, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC809 (FAS) - (06/04)

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