198602608-7-26-2024-28-AS-CWOG-D7JUWF-20240726155642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602608
Report Date: 07/26/2024
Date Signed: 07/26/2024 03:58:30 PM

Document Has Been Signed on 07/26/2024 03:58 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	IVY PARK AT CERRITOS		FACILITY NUMBER:	198602608
ADMINISTRATOR:	LAURA RODRIGUEZ		FACILITY TYPE:	740
ADDRESS:	11000 NEW FALCON WAY		TELEPHONE:	(562) 865-9500
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY:	163	CENSUS: 135	DATE:	07/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Laura Rodriguez -Administrator		TIME COMPLETED:	04:20 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	Licensing Program Analyst (LPA) Wong conducted the Unannounced required annual inspection. LPA arrived unannounced and met with Administrator Laura Rodriguez and assisted with the visit. The purpose for the visit was explained. The facility is licensed for age range 60 and over and 163 non-ambulatory residents. Currently, the facility has 9 hospice waiver residents and 8 home health residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control Plan: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan in place. LPA reviewed staff files and observed two staff does not have chest x ray result and one staff does not have health screening in file. 2. Operational Requirement: The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 25 residents is approved. A fire clearance approved for 163 non-ambulatory residents. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($10,000,000) is in place. 3. Physical Plant and Environmental Safety: LPA toured the facility with the Executive Director Laura Rodriguez. This 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. LPA inspected 10 residents' rooms and each resident bedroom has the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT CERRITOS	FACILITY NUMBER: 198602608
	VISIT DATE: 07/26/2024

NARRATIVE

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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 between 107.6 and 116.4 degrees F which is with in the Title 22 regulation. The carbon monoxide detectors and smoke detectors are interconnected and all tested and they are all working well.

4: Staffing: Facility has sufficient staffing for care and supervision to the residents. All the staff in the facility are over 18 years old, background clearance and associated with the facility. The administrator is Laura Rodriguez and her administrator certificate is effective through 3/3/25 and she has all the required training hours and staff has the required training hours annually.

5. Personnel Record-Training : LPA reviewed staff files and they have the required documents included employee application and they have at least one person has the required CPR training certificate

6. Resident Right Information: LPA observed the required posters posted in the facility which include Long Term Care Ombudsman located on the second floor next to the resident's laundry room, and the Community Care Licensing Complaint and Personal Right Poster are located on the first floor nearby the resident's mailbox. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician.

7. Planned Activity: Facility has sufficient space to accommodate for indoor and outdoor activity. LPA also observed the weekly activity calendar and it's posted in the facility. The facility does have an active Resident Council.

8. Food Service: Currently the facility has about 5 residents who are required the modified diet and LPA reviewed and observed the doctor's order. The facility has ample supply for two days perishable and seven days non-perishable food supply. The facility also has emergency food supplies and water located on the first floor. All the food are stored properly. 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. Walls and floors, cabinets and counters were clean and sanitary throughout the facility.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT CERRITOS	FACILITY NUMBER: 198602608
	VISIT DATE: 07/26/2024

NARRATIVE

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9. Incidental Medical and Dental: Nine (9) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided if needed.

10. Resident Record-Incident Reports: LPA inspected 10 resident files and they all have the required documents in file which include: Identification and Emergency Information, Pre-admission appraisal, admission agreement, recent medical assessment and TB test result, medical consent and medication record.

11. Disaster Preparedness: The facility has an updated LIC610E Emergency Disaster Plan. The facility has two alternative shelter location for emergency. The last fire /disaster drill was conducted on 5/15/24. LPA also observed the evacuation chair at each stairwell. Records of resident Appraisal and Needs services plans are part of Emergency training.

12. Residents with Special Health Needs: Night (9) residents are receiving hospice services. Eight (8) residents receive home health services. No resident in the facility is on any postural support.
Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Executive Director Laura Rodrigeuz. A copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/26/2024 03:58 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
GREATER LA AC/SC, 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: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed one staff does not have health screening and TB test result and one staff does not have the TB test result which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	The administrator will ensure all staff would have the health screening and chest x ray performed by a physician not more than 6 months prior to seven (7) days after employment or licensure. The administrator will send their health screening form and chest x ray to LPA by POC due date.

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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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