565802461-5-24-2024-29-AS-DPEA-D5RS5H-20240530133424

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802461
Report Date: 05/24/2024
Date Signed: 05/24/2024 04:22:20 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2024 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20240520121641

FACILITY NAME:	IVY PARK AT WOOD RANCH		FACILITY NUMBER:	565802461
ADMINISTRATOR:	EDITH KENNEDY		FACILITY TYPE:	740
ADDRESS:	190 TIERRA REJADA RD		TELEPHONE:	(805) 584-8881
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	100	CENSUS: 66	DATE:	05/24/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jeanne Skondin		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff did not ensure that resident's shower was in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint visit for the above allegation. Upon arrival, the LPA met with Executive Director (ED), Jeanne Skondin and explained the reason for the visit. Entrance interview conducted.

During today's visit, the LPA along with the ED conducted a plant tour to ensure there are no health and safety issues at 10:18 a.m., observed four (4) random bedrooms and one (1) common restroom between 10:30 a.m. and 11:10 a.m., conducted interviews with the ED, six (6) staff members, and one (1) resident between 9:50 a.m. and 2:40 p.m., and obtained copies of pertinent documents relevant to the investigation.

Continued on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

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 29-AS-20240520121641

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT WOOD RANCH	FACILITY NUMBER: 565802461
	VISIT DATE: 05/24/2024

NARRATIVE

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Continued from LIC 9099...

It was alleged that facility staff did not ensure that resident’s shower was in disrepair. It was reported that Resident #1’s (R1’s) shower pressure and hot water temperature was low. Records reviewed revealed that facility emailed a letter to both residents and family members notifying them on current facility updates. In this letter, the facility states that the maintenance team has been hard at work repairing a plumbing project. Interviews conducted with staff revealed the facility has two (2) water heaters that supply the hot water for the entire building and added that while inspecting the water heaters, it was revealed that the smaller water heater needed re-piping. Staff stated that after the plumbing company fixed the water heater issue, the facility figured the water temperature issue in all rooms including R1’s shower would be corrected. However, the water pressure and hot water temperature in R1’s shower did not correct itself after the water heater had been fixed. The plumber then inspected R1’s shower and found that the cartridge in the shower valve was not working properly. However, staff interviews further revealed that R1’s water issue in their shower was being communicated to management for several weeks. Additionally, record review of progress notes dated, 05/17/2024 stated that R1 had communicated with the ED regarding the issue with their shower. Although the facility accommodated R1 by allowing them to take showers in a different apartment, the facility did not test R1’s shower to ensure that it was not faulty prior to the fixing of the water heater. Based on the information obtained and reviewed, the allegation of, “facility staff did not ensure that resident’s shower was in disrepair” is being deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 the following deficiencies were observed and cited. Refer to the following LIC 809-D pages for list of deficiencies.

Exit interview conducted. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20240520121641

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT WOOD RANCH	FACILITY NUMBER: 565802461
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/24/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility had a plumber fix R1's shower pressure and water temperature during today's visit. POC has been met.
	8 9 10 11 12 13 14	Based on LPA observation, interviews, and records review, the licensee did not comply with the section cited above as R1's shower was not fixed for several weeks even after it was reported to management, which poses a potential health and safety risk to the residents in care.	8 9 10 11 12 13 14
	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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

LIC9099 (FAS) - (06/04)

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