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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602608
Report Date: 04/19/2024
Date Signed: 04/19/2024 11:39:49 AM


Document Has Been Signed on 04/19/2024 11:39 AM - 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:LAURA RODRIGUEZFACILITY TYPE:
740
ADDRESS:11000 NEW FALCON WAYTELEPHONE:
(562) 865-9500
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:163CENSUS: 133DATE:
04/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kris Schero- Marketing DirectorTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of citing deficiencies. LPA Maldonado met with and explained the purpose for the visit.

During the investigation conducted for a complaint, dated: 1/30/23, it was discovered that in November 2022, Resident#1 (R1) sustained a fall at the facility that resulted in a hip fracture and required surgery. At the time of the incident, R1 was not deemed a fall risk. After surgery, R1 was transferred to a skilled nursing facility to recuperate from the surgery, and returned to the facility on 12/09/22. Per facility shift report dated 1/18/23, R1 was to have status checks during night shifts every (2) hours. Per facility incident reports dated 1/20/23 and 1/30/23, it was documented that R1 sustained (2) falls on 1/20/23 at 1:45AM and 4:30AM, and (1) fall on 1/30/23 at 11:20PM. Upon being notified of more frequent falls, R1's family decided to hire a private caregiver to provide 1:1 night supervision to R1 to keep R1 from falling out of bed. Per staff interviews conducted during the investigation of the complaint, (7) of (7) staff admitted to having knowledge of R1 becoming more agitated at night and trying to get up out of bed, which resulted in frequent falls. Staff stated this was due to R1's progression of R1's cognitive impairment. After review of R1's updated facility service plan, dated: 11/25/22, R1 had a change in condition which required R1 to have hands on assistance for repositioning in bed due to becoming bedridden. Following the incident reports of falls sustained by R1, there was no update to R1's service plan/plan of care to reflect that R1 was now a fall risk. The facility failed to put a plan in place to prevent R1 from sustaining continued falls, while in care.

Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC809-D page.

Exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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 04/19/2024 11:39 AM - 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: 04/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2024
Section Cited
CCR
87705(5)(A)

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87705 Care of Persons with Dementia
(5) Each resident with dementia shall have an annual medical assessment…and a reappraisal done…(A)When…observation indicates that the resident’s needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.
This requirement was not met as evidenced by:
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Licensee will submit a plan in writting on how they will ensure to update resident records as needed, especially if a change in condition is observed. Plan to be emailed to LPA by POC due date.
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Based on record review and interviews, the Licensee failed to update R1's Physician's Report and Appraisal to indicate that R1 was now a fall risk, which poses a potential 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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
LIC809 (FAS) - (06/04)
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