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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602608
Report Date: 07/31/2025
Date Signed: 07/31/2025 02:40:12 PM

Document Has Been Signed on 07/31/2025 02:40 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:IVY PARK AT CERRITOSFACILITY NUMBER:
198602608
ADMINISTRATOR/
DIRECTOR:		LAURA RODRIGUEZFACILITY TYPE:
740
ADDRESS:11000 NEW FALCON WAYTELEPHONE:
(562) 865-9500
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 163CENSUS: 137DATE:
07/31/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Carmen Hernandez, Business Office ManagerTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daniel Konishi conducted the unannounced required annual inspection. LPA met with the Business Office Manager, Carmen Hernandez and the purpose for the visit was explained. The facility is licensed for the age range 60 and over and 163 non-ambulatory residents. Currently, the facility has six (6) hospice waiver residents and seven (7) home health residents.

The initial annual visit was conducted on 07/29/2025. During the initial visit the following eight (7) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant Environmental Safety, Resident Rights-Information, Planned Activities, Food Services, Incidental Medical and Dental, Disaster Preparedness.

During today’s annual visit, the following five (5) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Operational Requirements, Staffing, Personnel Records-Training, Resident Records-Personnel Reports, Resident with Special Health Needs.

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. Based on record review, LPA observed that the facility has valid Liability Insurance in place. However, based on record review and observation, the facility has one (1) resident that is bedridden.

Staffing: Facility has sufficient staffing for care and supervision for the residents.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: IVY PARK AT CERRITOS
FACILITY NUMBER: 198602608
VISIT DATE: 07/31/2025
NARRATIVE
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Personnel Record-Training: LPA observed ten (10) staff files which include: health screening, TB test results, personnel records, criminal record clearance, current First-Aid training certificates, medication assistance training, and other ongoing training. Administrator’s certificate expires on 3/3/2027. The Administrator has all the required training hours and staff has the required training hours annually. Based on record review, LPA observed that Staff #3 (S3), Staff #4 (S4), Staff #5 (S5) and Staff #6 (S6) did not have valid first aid training in file. Based on record review, LPA observed that Staff #1 (S1’s) file did not have an TB test result

Resident Record-Incident Reports: LPA inspected fourteen resident files and they all have the required documents in file which include: Face sheet, Identification and Emergency Information, Pre-admission appraisal, admission agreement, recent medical assessment, ambulatory status, TB test result, appraisal/services and needs plan, and personal rights. Based on record review, LPA observed that Resident #6 (R6’s) file with Dementia did not have an updated medical assessment.



Residents with Special Health Needs: Six (6) residents are receiving hospice services. Seven (7) residents receive home health services. No resident in the facility is on any postural support. No residents have prohibited health conditions.

Immediate Civil Penalties is issued on today’s visit in the amount of $500.00 due to facility retaining one (1) bedridden resident (R13).

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the as provided to the Business Office Manager, Carmen Hernandez.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/31/2025 02:40 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/31/2025 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department...

This requirement is not met as evidenced by:
Deficient Practice Statement
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The facility license was approved to retained 163 non-ambulatory and hospice approved for 25 residents and currently LPA observed based on record review of Resident#13 (R13) physician’s report and observation that R13 is (1) bedridden resident at the facility. This poses an immediate health, safety or personal rights risk to persons in care. **Immediate civil penalty will be assessed**.
POC Due Date: 08/01/2025
Plan of Correction
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Licensee will notify the local fire department/Fire Marshall today that the facility is retaining one (1) bedridden resident without a bedridden fire clearance. Licensee will submit LIC 200, facility sketch, and identify the rooms for bedridden resident(s) to the licensing department immediately no later than 08/01/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/31/2025 02:40 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/31/2025 at 02:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87411(c)(1)
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that Staff #3 (S3), Staff #4 (S4), Staff #5 (S5) and Staff #6 (S6) did not have valid first aid training in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2025
Plan of Correction
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Executive Director will send Staff #3 (S3), Staff #4 (S4), Staff #5 (S5) and Staff #6 (S6’s) valid first aid training to the LPA by the POC due date.
Daniel.Konishi@dss.ca.gov
Type B
Section Cited
CCR
87411(f)
(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
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Based on record review, Staff #1 (S1’s) file did not have an TB test result which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2025
Plan of Correction
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Executive Director will send Staff #1 (S1’s) TB test result to the LPA by the POC due date.
Daniel.Konishi@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/31/2025 02:40 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/31/2025 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87705(c)(5)
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that Resident #6 (R6’s) file with Dementia did not have an updated medical assessment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2025
Plan of Correction
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Executive Director will submit Resident #6 (R6's) updated medical assessment to the LPA by the POC due date.
Daniel.Konishi@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
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