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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602882
Report Date: 11/03/2023
Date Signed: 11/03/2023 02:30:39 PM


Document Has Been Signed on 11/03/2023 02:30 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 CLAREMONTFACILITY NUMBER:
198602882
ADMINISTRATOR:ENDERT, ROGERFACILITY TYPE:
740
ADDRESS:2053 N TOWNE AVETELEPHONE:
(909) 398-4688
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:81CENSUS: 45DATE:
11/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Administrator, Daisy Hernandez TIME COMPLETED:
02:47 PM
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LPA made unannounced visit to reissue citation dated 03/01/2023 to facility. The purpose of the visit was discussed along with the Licensee’s responsibilities in regard to documents subpoenaed by the department and to issue a deficiency for failing to provide records under Title 22 Regulations, Section 87755.

Section 87755 Inspection Authority of the Licensing Agency

The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b).

· Licensee will provide requested records that were subpoena and served on 08/03/2021



The following document are requested to be submitted to the Department by 11/07/23.

· Resident/General Liability Incident Report for Resident #1 dated 6/25/20

· Fall Investigation Worksheet for Resident #1, dated 6/26/20

· Resident/General Liability Incident Report for Resident #1, dated 6/26/20

· Resident/General Liability Incident Report for Resident #2, dated 7/04/20

· First “Resident/General Liability Incident Report for Resident #2, dated 9/21/20

Continue on LIC809D

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 11/03/2023
NARRATIVE
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  • Second “Resident/General Liability Incident Report for Resident #2, dated 9/21/20

The Administrator/Licensee have been advised to comply with Title 22 Section 87755(c) Inspection Authority of the Licensing Agency and all other Regulations of Title 22.

Administrator advised to send requested documents to the Monterey Park Adult &Senior Regional Office and the Investigation Branch.

Deficiency cited during today's visit, refer to LIC809D for details.



Administrator was informed that Civil penalties may be assessed if Licensee does not comply by POC due date.
Administrator will fax to Monterey Park Adult &Senior Regional Office (323) 980-4912 and Investigation Branch (323)-9813876 documents POC date and follow up with email.

Exit interview conducted with Executive Director Daisy Hernandez and copy of this licensing report and appeal rights has been provided and discussed with Executive Director Daisy Hernandez

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/03/2023 02:30 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: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/07/2023
Section Cited
CCR
87755(c)

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87755(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary, for copying.

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Licensee will provide all documents to Department and investigation branch by POC date via fax and follow-up with confirmation email.
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As of 11/03/2023, the department has not received the requested documentation that was requested by serving subpoena in person on 08/03/2021 and citation will is issued under section 87755

Facility has not provided requested documentation/records that include:1. “Resident/General Liability Incident Report” R1, dated 6/25/20
2. “Fall Investigation Worksheet” for R1, dated 6/26/20
3. “Resident/General Liability Incident Report” R1, dated 6/26/20
4. “Resident/General Liability Incident Report” for R2, dated 7/04/20
5. First “Resident/General Liability Incident Report” R2, dated 9/21/20
6. Second “Resident/General Liability Incident Report” R2, dated 9/21/20
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
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