198602882-2-15-2024-28-AS-KRAZ-D2GVJK-20240215152852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602882
Report Date: 02/15/2024
Date Signed: 02/15/2024 03:29:12 PM

Document Has Been Signed on 02/15/2024 03:29 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 CLAREMONT		FACILITY NUMBER:	198602882
ADMINISTRATOR:	HERNANDEZ, DAISY		FACILITY TYPE:	740
ADDRESS:	2053 N TOWNE AVE		TELEPHONE:	(909) 398-4688
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	81	CENSUS: 45	DATE:	02/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:17 AM
MET WITH:	Administrator Dasiy Hernandez		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Christian Gutierrez conducted an unannounced Required 1-year Visit on 02/15/2024. LPA was met by Resident Care Provider- Veronica Hermisillo and explained the purpose of the visit. The facility is licensed to serve eighty-one (81) residents over the age of 60, of which eighty-one (81) may be non-ambulatory and has a hospice waiver approved for fifteen (15).

LPA OBSERVATIONS: Tour began at 8:30 am and was led by Veronica Hermisillo. The facility has a memory care unit and is approved for delayed egress.

Front Yard: Was clean and well maintained. No hazards were observed. No large bodies of water were observed.

Kitchen: LPA’s observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA’s observed knives and sharps to be inaccessible to residents in care. LPA’s observed kitchen staff cleaning kitchen area and preparing lunch.

Dining Room/Living room/: Dining room was observed to be clean, contain plenty of seating and have sufficient lighting. LPA’s observed near by thermostat to read 73 degrees F.

Laundry room: Laundry room is accessible to assisted living residents.

SEE 809-C for continuation.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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 CLAREMONT	FACILITY NUMBER: 198602882
	VISIT DATE: 02/15/2024

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Resident Rooms: LPA’s inspected a total of four (4) resident bedrooms in the assisted living section and observed all bedrooms to contain required furnishings, lighting, and linens. LPA’s observed over the counter and prescribed medication in R6’s bathroom mirror cabinet. Per R6’s physician’s report, R6 may not store and administer own medication. LPA will issue Type A deficiency based on observation. LPA’s toured four (4) resident rooms in memory care unit and observed all bedrooms to contain required furnishings, lighting, and linens.

Bathrooms: Water temperature in randomly selected rooms were tested and measured to be within the required 105 – 120 degrees F. LPA’s observed grab bars in bathrooms and showers were treated with non-slip coating.

Backyard: Clean and free from hazards. LPA’s observed plenty of seating and shade. No large bodies of water were observed.

Memory Care Unit: LPA’s observed delayed egress doors leading into unit entrance. LPA’s observed facility staff conducting exercise activities with residents in living room area. LPA’s observed kitchenette to be clean and appliances were observed to be in working condition.

Emergency Drills/Emergency Disaster Plan: Last documented fire drills were conducted on 01/31/24 and 12/28/23.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA’s observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA’s reviewed eight (8) personnel records. Documented proof of required annual initial training and annual training were observed. Administrator's Certificate for Daisy Hernandez was observed with an expiration date of 02/07/2025 (6065952740).

Resident Records: Eight (8) resident files were reviewed.

Liability Insurance & Infection Control Plan: LPA’s obtained a copy of liability insurance during visit. LPA’s observed updated infection control plan.

Exit interview was conducted. One (1) deficiency was cited during visit. A copy of this report, 809-D and appeals rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/15/2024 03:29 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 CLAREMONT	FACILITY NUMBER: 198602882
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, R6 had medication stored in bathroom cabinet, per medical assessment, R6 may not store own medications or administer, the licensee did not comply with the section cited above in 1 out of 31 residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	Staff removed medication during visit. This clears part of POC for 24hr correction. Licensee will retrain staff on above regulation and send proof of retraining by 2/29/2024, via email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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