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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602608
Report Date: 09/14/2023
Date Signed: 09/14/2023 02:25:48 PM


Document Has Been Signed on 09/14/2023 02:25 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:
09/14/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Executive Director Laura Rodriguez TIME COMPLETED:
02:40 PM
NARRATIVE
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On 9/14/23 at 9:22 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual Continuation visit at Ivy Park Cerritos. Upon arrival LPA was greeted by Executive Director Laura Rodriguez. This home is licensed to serve (163) non-Ambulatory residents ages 60 and over, with a hospice waiver for 10. The last emergency disaster/fire drill was conducted on 8/23/23. The Administrator Certificate expired on 3/4/2021 #6051234740. LPA observed that the administrator certificate is processing and is currently on the pending list. During today's visit LPA reviewed (5) staff files, (13) resident files, medications, and medication administration records for (13) residents.

LPA inspected the medications and observed PRN medications for resident R1 through R5 was missing. Med staff stated they will review all resident’s medication and discontinue or reorder the medication.
· R1 is missing Diphenoxylate, Diclofenac, Lidocaine, and Loperamide.
· R2 is missing I Prat- Albuterol and Novolin R 100.
· R3 is missing Alprazolam and Milk of magnesia.
· R4 is missing Hydrocodone with Acetaminophen
· R5 is Missing Acetaminophen 500, Bisacodyl, Geri-Lanta, and Robafen


The following Deficiencies were cited on the LIC809D. Exit interview conducted with Laura Rodriguez, Executive director a copy of this report was provided, and Appeal rights given.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
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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Document Has Been Signed on 09/14/2023 02:25 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 CERRITOS
FACILITY NUMBER: 198602608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/15/2023
Section Cited
CCR
87465(c)(2)

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Incidental Medical and Dental Care Services. Once ordered by the physician, nonprescription PRN medications shall be given in accordance with the physician’s directions.

This requirement is not met as evidenced by:
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The facility will ensure that Residents have PRN medications ordered by the physician available at the facility at all times. Medication staff stated they will review all resident medications and discontinue or reorder the medications. Supporting documents will be required as proof of completion to LPA by POC due date.
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Based on observation, PRN medications was missing without a discontinued order, which poses an immediate health, safety, or personal rights risk 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) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
LIC809 (FAS) - (06/04)
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