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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602608
Report Date: 08/15/2023
Date Signed: 08/15/2023 02:42:12 PM


Document Has Been Signed on 08/15/2023 02:42 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 CERRITOSFACILITY NUMBER:
198602608
ADMINISTRATOR:LILIT CHAPARYANFACILITY TYPE:
740
ADDRESS:11000 NEW FALCON WAYTELEPHONE:
(562) 865-9500
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:163CENSUS: 130DATE:
08/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director Laura Rodriguez TIME COMPLETED:
03:00 PM
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On 8/15/23 at 9:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Ivy Park Cerritos. Upon arrival LPA was greeted by Executive Director Laura Rodriguez the reason for the visit. This facility is licensed to serve 163 residents age 60 and over with non-ambulatory capacity of 163. The facility currently has an approved hospice waiver for 10. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, interviewed (5) staff, and interviewed (10) residents.

LPA toured the physical plant with the Executive Director Laura Rodriguez and Regional Health Services Specialist Adriana RuizThis property is comprised of one large two story building on 5.5 acres and contains (90) studio apartments, (42) - 1-bedroom apartments, (12) 2- bedroom apartments, first floor; Lobby/Front desk reception area, administrative offices, Computer room, Salon, Coffee Lounge, Dining room, Kitchen, Community Laundry room, Housekeeping Storage closet, Men/Women restroom, (2) utility rooms. Second floor; Program Director office, Director of Nursing office, Staffing Coordinator office, Medication room, Library, Fitness Center, Theater/Multipurpose room, Men/Women restroom, (4) utility rooms, Storage room (emergency food supplies) and (PPE supplies). The outdoor grounds contained body of water in a fountain, East Wing Courtyard, West Wing Courtyard and community park. Passageways, walkways, and patios are free from obstructions and hazards. The facility is equipped with central air and heat. The resident’s bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid matt/strips and shower chair. The temperature measured at 105 *F- 120*F. The smoke detectors were tested and observed to be working properly. The carbon monoxide detector was functioning properly. There were fire extinguishers located throughout the facility, fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked. The pantry was well stocked, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the facility.

(Report continued on LIC809C.)

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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 CERRITOS
FACILITY NUMBER: 198602608
VISIT DATE: 08/15/2023
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Upon return LPA will review medications, review staff and resident files, review staff training, and finalize care tools.

Exit interview conducted with Laura Rodriguez and Adriana Ruiz, a copy of this report was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC809 (FAS) - (06/04)
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