198603729-8-22-2024-28-AS-TVAO-D9GPEB-20240926111449

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603729
Report Date: 08/22/2024
Date Signed: 08/22/2024 04:58:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2024 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240819124811

FACILITY NAME:	IVY PARK AT CLAREMONT		FACILITY NUMBER:	198603729
ADMINISTRATOR:	HERNANDEZ, DAISY		FACILITY TYPE:	740
ADDRESS:	2053 NORTH TOWNE AVE		TELEPHONE:	(909) 398-4688
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	81	CENSUS: 61	DATE:	08/22/2024
		UNANNOUNCED	TIME BEGAN:	08:19 AM
MET WITH:	Business Office Director Lachaun Gill		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff does not treat resident with respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/22/2024 regarding the above allegation. LPA Ramirez was greeted by Business Office Director Lachaun Gill and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff roster, Staff#1 - 9 interviews (S1 – S9), Attempted interview of Staff#10 (S10), Interview of Resident#1 (R1), Attempted interview of Residents in Evergreen Unit, copies of Resident#1 (R1) Physician’s Report, Identification and Emergency Information, Copy of Staff#10 (S10) Employment Application, Copy of (S10) fingerprint clearance, three (3) written statements from facility staff, and physical plant tour.

See 809-C for continuation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240819124811

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 198603729
	VISIT DATE: 08/22/2024

NARRATIVE

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The investigation revealed the following. Regarding Allegation: Staff does not treat resident with respect - It is alleged that S10 shouted and did not treat R1 with dignity on or around 8/17/2024. Five (5) out nine (9) staff verbally interviewed corroborate this allegation. LPA Ramirez observed three (3) written statements by three facility staff that corroborate this allegation. S10 was not available for interview during visit and LPA Ramirez attempted to contact S10. According to staff, S10 resigned effective 8/22/2024. One (1) out of one (1) resident interviewed deny this allegation. Residents that reside in the Evergreen unit suffer from cognitive impairments; LPA Ramirez was unable to conduct additional resident interviews. During staff interviews and records reviewed, it was revealed that on multiple occasions S10 was observed by other staff to shout and refuse to assist residents with activities of daily living. Written statements by facility staff revealed on 7/15/2024, S11 documented that S10 left R3 soiled in feces for more than 4 hours. LPA Ramirez observed a written statement by S5 that documented on or around 5/15/24 or 5/16/24, S10 raised their voice at residents’ family while searching for a resident’s shirt. Interviews with staff revealed S10 was heard redirecting residents by shouting and refusing to assist other staff reposition residents upon request. Based on interviews and and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

One (1) deficiency is being cited during this investigation. Exit interview was conducted. 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: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240819124811

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 198603729
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/29/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not as evidenced by:	1 2 3 4 5 6 7	5 out of 9 staff inteviews confirm this allegation. 3 written statments by staff confirm this allegation. S10 was observed shouting at and refusing to assist residents Licensee will retrain staff on regulation 87468.1 (a)(1) by 8/29/24 and send proof of retrainig via email.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC9099 (FAS) - (06/04)

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