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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602608
Report Date: 04/19/2024
Date Signed: 06/13/2024 09:45:05 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2023 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230130161858
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: 133DATE:
04/19/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Laura Rodriguez- Executive DirectorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not follow resident's care plan resulting in resident obtaining a prohibited health condition.
INVESTIGATION FINDINGS:
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**Please note: This licensing report has been amended to remove confidential information. However, the findings of this report will not change.**
Licensing Program Analysts (LPA's) V. Maldonado and Tyler Reyes made an unannounced subsequent visit to the facility, for the purpose of delivering the amended report. LPA met with Executive Director, Laura Rodriguez, and explained the reason for the visit.
On 04/19/24, LPA Maldonado made an unannnounced visit to the facility to deliver findings regarding the above-mentioned allegation. LPA Maldonado met with staff, Kris Schero, and explained the purpose for the visit.
On 01/31/23, LPA Ashley Calderon conducted a health and safety inspection. The visit consisted of the following: A tour of the physical plant with Carmen, residents rooms# 103,109,126,136, 279, 204 and 205, and common areas. LPA also observed food supplies, and obtained a copy of the staff and resident rosters, and the following documents for Resident #1: Admission agreement, Emergency Identification, previous and current Physicians Report, Resident Assessment, Physician Orders/Medication List, Dignity Palliative Hospice Care Reports, Hospice Plan of Care, Progress Notes, Outside Provider Communication Logs, Resident Care Notes, Recent Doctor visit reports, Indicent Reports, Individualized Service Plan and the Appraisal/Pre Appraisal Needs and Services Plan. LPA observed facility and residents in care and did not observe there to be any health and safety concerns.
(Report Continued on LIC9090-C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 28-AS-20230130161858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/19/2024
NARRATIVE
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On 04/04/24, LPA Maldonado made a subsequent visit and met with Executive Director, Laura Rodriguez. During the visit, LPA obtained a copy of the resident and staff rosters, and conducted interviews with Staff# 8-14 (S8-S14), and Residents# 2-7 (R2-R7). LPA also obtained copies of the following documents for R2-R7: Facesheet, Physician's Report, and Needs and Services Plan. LPA was unable to interview Resident#1 (R1) due to R1 deceased.

The investigation for the above-mentioned allegation was conducted by the department. The investigation consisted of the following: Interviews conducted with Staff#1-7 (S1-S7) and Witness# 1-2 (W1-W2), and obtained the following records for R1: Facility Service Plan, Resident Assessment, Individualized Service Plan, facility Assessment Notes dated: 08/08/22, 09/12/22, and 11/25/22, facility shift reports, facility Communication notes from Hospice, Hospice Care Notes, Transfer/Discharge report from Skilled Nursing facility, Hospital records dated 12/14/22. R1 was not interviewed due to R1 deceased.
The investigation revealed the following:

Staff did not follow resident's care plan resulting in resident obtaining a prohibited health condition.
It is alleged that per R1's care plan, R1 was required to be repositioned every (2) hours, however staff did not follow the care plan, which lead R1's Stage I pressure wound to become a Stage III pressure wound. Per the investigation, R1 sustained a fall at the facility in November 2022 which resulted in a hip fracture. Following surgery from the fracture, R1 was at a skilled nursing facility where R1 developed a Stage I pressure wound on the buttocks due to R1 becoming bedridden. Per R1's updated facility service plan, dated: 11/25/22, R1 had a change in condition which required R1 with hands on assistance for repositioning in bed due to becoming bedridden. Per staff interviews, (7) of (7) staff stated that R1 was repositioned as per R1's care plan. However, R1 was repositioning self onto R1's back after being repositioned by staff. Per records review, it was discovered that the facility did not update R1's care plan to address R1 repositioning self back after being repositioned by facility staff, which led to R1's Stage I pressure wound becoming a Stage III pressure wound. Therefore, this allegation is Substantiated.

Based on observation and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.


Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on LIC9099-D.
Immediate Civil Penalties in the amount of $500 will also be issued.
An 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: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2023 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230130161858

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: 133DATE:
04/19/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Laura Rodriguez- Executive DirectorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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3
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9
Resident in care sustained multiple falls resulting in a hip fracture while in care.
Resident fell and was left unattended on the floor for an extended period of time.
Resident is not being transferred out of bed by staff on routine basis.
Staff are not assisting resident with oral hygienes & dressing.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**Please note: This licensing report has been amended to remove confidential information. However, the findings of this report will not change.**
Licensing Program Analysts (LPA's) V. Maldonado and Tyler Reyes made an unannounced subsequent visit to the facility, for the purpose of delivering the amended report. LPA met with Executive Director, Laura Rodriguez, and explained the reason for the visit.
On 04/19/24, LPA Maldonado made an unannnounced visit to the facility to deliver findings regarding the above-mentioned allegation. LPA Maldonado met with staff, Kris Schero, and explained the purpose for the visit.
On 01/31/23, LPA Ashley Calderon conducted a health and safety inspection. The visit consisted of the following: A tour of the physical plant with Carmen, residents rooms# 103,109,126,136, 279, 204 and 205, and common areas. LPA also observed food supplies, and obtained a copy of the staff and resident rosters, and the following documents for Resident #1: Admission agreement, Emergency Identification, previous and current Physicians Report, Resident Assessment, Physician Orders/Medication List, Dignity Palliative Hospice Care Reports, Hospice Plan of Care, Progress Notes, Outside Provider Communication Logs, Resident Care Notes, Recent Doctor visit reports, Indicent Reports, Individualized Service Plan and the Appraisal/Pre Appraisal Needs and Services Plan. LPA observed facility and residents in care and did not observe there to be any health and safety concerns.
(Report Continued on LIC9090-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20230130161858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/19/2024
NARRATIVE
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The following allegation was investigated by the department:
  • Resident in care sustained multiple falls resulting in a hip fracture while in care.
The investigation consisted of the following: Interviews conducted with Staff#1-7 (S1-S7) and Witness# 1-2 (W1-W2), and obtained the following records for R1: Facility Service Plan, Resident Assessment, Individualized Service Plan, facility Assessment Notes dated: 08/08/22, 09/12/22, and 11/25/22, facility shift reports, facility Communication notes from Hospice, Hospice Care Notes, Transfer/Discharge report from Skilled Nursing facility, Hospital records dated 12/14/22. R1 was not interviewed due to R1 deceased.
The investigation revealed the following:

Regarding allegation: Resident in care sustained multiple falls resulting in a hip fracture while in care.
It is alleged that R1 had multiple falls while in care at the facility, which resulted in R1 sustaining a hip fracture that required surgery. Per the investigation, R1's first documented fall occurred in November 2022. The fall that occurred at that time resulted in R1 sustaining a hip fracture. Per R1's Pre-Placement appraisal and Individualized Service Plan, R1 was not a fall risk at this time. R1 returned to the facility on 12/09/22 and was placed on hospice to receive wound care due to R1 being bed bound and sustaining wounds while in a skilled nursing facility, following recovery from the hip surgery. Per R1's hospice records dated 1/20/23, 1/30/23, and facility shift reports dated 1/20/23 and 1/26/23, it was noted that R1 was found by caregivers on the floor, tangled in R1's blankets with no visible injuries. From 2/07/23 through 2/10/23, R1's family hired a private caregiver through a home health company to provide 1:1 care to R1 during the night, as it was noted that R1 was getting up at night and sustaining more frequent falls. Per staff interviews, (7) of (7) staff stated they did not witness R1's falls. R1 was found on the floor during their regular status checks. Staff also stated that due to R1's falls were becoming more frequent due to R1's progression of R1's cognitive impairment. The allegation suggests that the multiple falls culminated in the resident sustaining a hip fracture. There was no evidence to prove that R1 was a fall risk prior to the fall that resulted in a hip fracture. Therefore, this allegation is Unsubstantiated.

On 04/04/24, LPA Maldonado made a subsequent visit and met with Executive Director, Laura Rodriguez. During the visit, LPA obtained a copy of the resident and staff rosters, and conducted interviews with Staff# 8-14 (S8-S14), and Residents# 2-7 (R2-R7). LPA also obtained copies of the following documents for R2-R7: Facesheet, Physician's Report, and Needs and Services Plan. LPA was unable to interview Resident#1 (R1) due to R1 deceased.
(Report Continued on LIC9099-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20230130161858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/19/2024
NARRATIVE
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During the visit, LPA Maldonado investigated the following allegations:
  • Resident fell and was left unattended on the floor for an extended period of time.
  • Resident is not being transferred out of bed by staff on routine basis.
  • Staff are not assisting resident with oral hygienes & dressing.

Regarding allegation: Resident fell and was left unattended on the floor for an extended period of time. It is alleged that on 1/19/23, R1 fell out of bed and was found on the floor by facility staff about (3) to (4) hours later, on 1/20/23. Per incident reports dated 1/20/23, R1 was found on the floor at 1:45AM during status check rounds conducted by facility staff. It was noted that R1was assessed for injuries and assisted back into bed. At 4:45AM, during status check rounds, facility staff found R1 on the floor again. R1 was assessed for injuries again and was assisted back into bed by staff. Per staff interviews, (7) of (7) staff denied the allegation. Staff stated that R1 was getting up at night more frequently, so R1 was placed on status checks every (2) hours. There is insufficient evidence to prove the amount of time R1 was on the floor for before staff found R1 while conducting their status checks. (6) of (6) residents interviewed could not corroborate the allegation.
Regarding allegation: Resident is not being transferred out of bed by staff on routine basis.
It is alleged that R1 is not being transferred out of bed on a routine basis and as a result, R1 is becoming more contracted. Per hospice records dated 2/04/23, R1 was to be assisted with repositioning every (2) hours due to a pressure ulcer on R1's coccyx and R1 being bedbound, and required assistance with transferring out of bed/chair. Per medical and hospice records, there is no indication that R1 was contracted. (7) of (7) staff interviewed denied the allegation. Staff stated that residents who require repositioning and assistance with transfers are assisted as required and as needed, based on their care plans. During interview with R2, R2 reported that staff come in frequently to assist with repositioning and transferring, as they require it. (5) of (6) residents interviewed could not corroborate the allegation.
Regarding allegation: Staff are not assisting resident with oral hygienes & dressing.
It is alleged that the facility is charging R1 an excessive amount of fees to provide services that R1 is not receiving, such as providing oral hygiene twice a day and assisting R1 with changing clothes daily, as R1 was found in only a shirt and briefs during the fall incident on 1/20/23. (7) of (7) staff interviewed denied the allegation and stated that R1 and other residents who require assistance with oral hygiene are assisted (2) to (3) times a day.

(Report continued on LIC9099-C...)
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
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20230130161858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/19/2024
NARRATIVE
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Staff stated sometimes residents may deny the care, however they will attempt at a later time and encourage them to complete the care. If residents continue to deny, it is charted and communicated to the staff on the incoming shift so that they may offer residents the care again. During interview with R2, R2 stated that staff assist R2 with oral hygiene care, changing clothes, and incontinence care frequently. (5) of (6) residents interviewed could not corroborate the allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Exit interview was conducted and a copy of this report was 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
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20230130161858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
04/20/2024
Section Cited
CCR
87463(a)(3)
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87463 Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...(3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.
This requirement was not met as evidenced by:
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Licensee will submit a plan in writing on how facility will esnure to document all resident changes in condition to prevent prohibited health conditions.
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Based on interviews and record review, the Licensee failed to update R1's appraisal to document that R1 was repositioning R1's self after staff were repositioning R1 that led to R1 sustaining a Stage III ulcer while in care, 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
LIC9099 (FAS) - (06/04)
Page: 7 of 7