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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204069
Report Date: 04/10/2025
Date Signed: 04/10/2025 01:55:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/27/2024 and conducted by Evaluator Troy Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241127150712
FACILITY NAME:IVY PARK AT SANTA MONICAFACILITY NUMBER:
198204069
ADMINISTRATOR:VILLARUZ, JUDITH UYFACILITY TYPE:
740
ADDRESS:1312 15TH STTELEPHONE:
(310) 899-1976
CITY:SANTA MONICASTATE: CAZIP CODE:
90404
CAPACITY:100CENSUS: 66DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Clifton Douyon - Executive DirectorTIME COMPLETED:
01:54 PM
ALLEGATION(S):
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Staff do not ensure facility fire alarm is in good repair.
INVESTIGATION FINDINGS:
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** This report supersedes the report dared 03/20/2025 and is being used to clarify the findings. It does not change the findings.

On 04/10/2025 Licensing Program Analyst (LPA) Troy Watson conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at the facility and was greeted by the Executive Director Clifton Douyon. LPA explained the purpose of the visit was to investigate and deliver findings and was granted entry.

CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 11-AS-20241127150712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: IVY PARK AT SANTA MONICA
FACILITY NUMBER: 198204069
VISIT DATE: 04/10/2025
NARRATIVE
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The investigation consisted of the following:

On 12/04/2024 Licensing Program Analyst (LPA) Troy Watson reviewed / obtained Resident Roster (dated 12/2024), Staff Roster (dated 12/2024), and Emergency Disaster Plan. Interviews were conducted, with Staff #1 – Staff #8 (S1-S8) and Residents #1- Residents#7 (R1-R7). The facility grounds were toured.

Investigation revealed the following:

Allegation: Staff do not ensure facility fire alarm is in good repair.

It is alleged that the smoke detector is broken and randomly goes off unexpectedly in the facility disturbing its residents. On 12/04/24 LPA Watson interviewed Staff#1 – Staff#8 (S1-S8) regarding the allegation. Of those interviewed 8 out of 8 staff agreed to the allegation. On 12/04/24 LPA Watson interviewed Residents #1- Residents #7 (R1-R7); 7 out of 7 residents interviewed agreed with the above allegation.

On 12/04/24 LPA Watson interviewed Executive Director Clifton Douyon. During the interview, Douyon stated that the smoke detectors located in room 118 and 221 were dysfunctional and needed repair. The director explained that they sounded off intermittently because of construction work being performed on the facility ceiling. During the interview it was also revealed that the triggering of the second smoke alarm was due to rainwater from the roof top of the ceiling.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20241127150712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: IVY PARK AT SANTA MONICA
FACILITY NUMBER: 198204069
VISIT DATE: 04/10/2025
NARRATIVE
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On 12/05/24 LPA Troy Watson interviewed and toured the facility grounds with the Maintenance Director Glen Olano, During the tour LPA observed and confirmed that the smoke detectors in rooms 118 and 221 were disconnected, and not functioning. During the interview Olan stated that an order for replacement or repair of the smoke detectors had been placed with Johnson Controls. LPA Watson requested records and called Johnson Controls to confirm the estimated time of repair or replacement of the smoke detectors multiple times. No confirmation of parts ordered or an estimated time of arrival for repairs could be confirmed.

Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Therefore, the allegation according to the California Code of Regulations (Title 22, Division 6, Chapter 8) has been Substantiated. The following deficiencies have been observed and a citation issued (ref. LIC 9099-D)

An exit interview was conducted with the Executive Director, Clifton Douyon and a hard copy of this report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20241127150712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: IVY PARK AT SANTA MONICA
FACILITY NUMBER: 198204069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2025
Section Cited
CCR
87303(a)
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Maintenance and Operation.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.
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Administrator will repair fire alarm system at the facility and will provide copies of receipts showing repairs have been made and fire alarm system is in good repair. The facility will email/fax by POC due dates. Administrator provided proof of repairs to LPA on 03/20/25 at time of visit.
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This requirement has not been met as evidenced by:On 12/04/2024 and 12/05/2024 LPA observed etc. that the fire alarm had been in disrepair and improperly malfunctioning for residents since (11/27/24). This is a potential health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4