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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603715
Report Date: 09/25/2026
Date Signed: 09/25/2026 04:29:47 PM

Document Has Been Signed on 09/25/2026 04:29 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:IVY PARK AT SAN MARINOFACILITY NUMBER:
198603715
ADMINISTRATOR/
DIRECTOR:		SANCHEZ, KIMBERLYFACILITY TYPE:
740
ADDRESS:8332 HUNTINGTON DRIVETELEPHONE:
(626) 292-7800
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 74CENSUS: 62DATE:
09/25/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Kimberly Sanchez, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced required- 1 year visit and met with the Executive Director, Kimberly Sanchez and LPA explained the purpose of the visit. The Facility is licensed to serve 74 non-ambulatory adults 60 and over, of which four (4) may be bedridden. Facility has an approved hospice waiver for 15 residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection Control Plan is in place. Infection control practices and Personal Protective Equipment (PPEs) were maintained. Housekeeping staff were observed maintaining sanitizing procedures.


Operational Requirements: Fire Clearance is in place. Facility does not handle resident monies. Valid Liability Insurance is in place. The last fire drill was conducted on 9/18/2026. The last emergency disaster drill was conducted on 9/18/2026.

Physical Plant/Environment Safety: The facility is two 2-story building consisting of "Evergreen" Memory Care Unit, 52 resident rooms, two (2) activity rooms, two (2) dining rooms, kitchen, dining room, two (2) boutique rooms, two (2) TV rooms, library, Bistro room, hair salon, administration offices, laundry rooms, storage areas, 1st floor courtyard/patio area with water fountain, 2nd floor terrace area, courtyard patio area, electrical rooms, staff break room, and parking garage.

[Continue to LIC809-C]

David Sicairos
Daniel Konishi
DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2026
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 SAN MARINO
FACILITY NUMBER: 198603715
VISIT DATE: 09/25/2026
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Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Seven (7) resident rooms, seven (7) resident bathrooms, common areas, and kitchen were inspected. Resident rooms have required furniture, bedding, linens, and lighting. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible to residents. Fireplace is covered and inaccessible to residents. The signal system was tested and is operational. LPA visited seven (7) randomly selected resident bathrooms which had hot water temperature readings that measured between 110.1 degrees F to 115.7 degrees F which is within the required 105 - 120 degrees Fahrenheit. LPA observed fire extinguishers that are fully charged and last inspected on 10/25/2025. The facility is equipped with sprinklers, smoke detectors, and carbon monoxide detectors. The last fire inspection was conducted on 6/4/2026 by Pasadena Fire Department.

Staffing: A total of 69 staff members provides care and supervision to the residents.

Personnel Records/Staff Training: LPA reviewed eight (8) staff files which included Personnel Record, valid First Aid/CPR training, Criminal Background Clearance, Health Screening, TB Clearance, Employee Rights, Medication Administration Training, Dementia Training, valid Food Handler’s Certificate, and Staff training. Administrator certificate expires 8/5/2027.

Resident Records/Incident Reports: LPA reviewed seven (7) resident files that included the Face Sheet, Admission Agreements, Pre-Placement Appraisal, Physician's Report, Ambulatory Status, TB Clearance, Individualized Service Plan, and Personal Rights.

Resident Rights-Information: Resident personal rights, complaint hotline information and visitors policy posters are posted in the mailing area. The facility provides internet service to all residents and have access to the facility phone.

Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed.

Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: IVY PARK AT SAN MARINO
FACILITY NUMBER: 198603715
VISIT DATE: 09/25/2026
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Incident Medical and Dental: LPA reviewed seven (7) residents’ medications. Medications are given as prescribed. Medications are centrally stored and locked in the medication cart. Resident medications which are centrally stored contain 30-day supply of medications. Medical and dental transportation is provided.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. The last fire drill was conducted on 9/18/2026. The last emergency disaster drill was conducted on 9/18/2026. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety.

Residents with Special Health Needs: Per Executive Director, there are currently seven (7) residents receiving hospice services, four (4) residents receive home health services, and no residents have prohibited health conditions. LPA reviewed two (2) residents’ hospice care plans. LPA reviewed one (1) resident’s Physician’s Order for half bed rails.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit Interview conducted and a copy of the report was provided to the Executive Director, Kimberly Sanchez.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
LIC809 (FAS) - (06/04)
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