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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320432
Report Date: 05/30/2025
Date Signed: 05/30/2025 04:38:25 PM

Document Has Been Signed on 05/30/2025 04:38 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:IVY PARK AT PLAYA VISTAFACILITY NUMBER:
198320432
ADMINISTRATOR/
DIRECTOR:		ELIGIO, NESTORFACILITY TYPE:
740
ADDRESS:5555 PLAYA VISTA DRIVETELEPHONE:
(310) 437-7178
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY: 102CENSUS: 74DATE:
05/30/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:13 AM
MET WITH:Executive Director Nestor MendezTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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On 05/29/25, Licensing Program Analysts (LPAs), Regina Cloyd and Jose Anguiano, conducted an announced visit to the facility for purpose of a prelicensing evaluation. On 05/30/25, Licensing Program Analysts (LPAs), Regina Cloyd and Alfonso Iniguez, conducted an announced visit to the facility for purpose of a prelicensing evaluation continuation. An application was submitted to Community Care Licensing Division (CCLD) for a change of ownership for a Residential Care Facility for the Elderly to serve the Elderly for 60 years and older. The requested capacity is for 102 residents of which 98 may be non-ambulatory and 4 may be bedridden. Any rooms on the first and second floor may be used for bedridden residents.

Structure:
The facility has six (6) floors which consists of: rooms 123-124, 127, 133-135, private dining, restaurant, bistro, kitchen, lobby, two (2) living rooms, lounge, laundry room, and three (3) solariums. Continue to LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198320432
VISIT DATE: 05/30/2025
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The second floor consists of: rooms 208-213, 215-216, 218-222, 224-227, activity studio, outdoor terrace, salon, hydro spa, and laundry room. The third floor (memory care) consists of: rooms 308-313, 315-316, 318-322, 324-327, living room, dining room, outdoor terrace, laundry room, kitchen, activity room, and storage. The fourth floor (memory care) consists of: rooms 408-413, 415-416, 418-422, 424-427, living room, kitchen, dining room, outdoor terrace, laundry room, activity lounge, and storage. The fifth floor consists of: rooms 505, 508-509, 511 – 515, 517-518, 520 – 522, activity studio, two (2) storages, and laundry room. The sixth floor consists of: rooms 603, 605-606, 609-612, 614-615, 617, and one storage.

Bedrooms:
LPAs inspected rooms 127, 135, 210, 213, 220, 225, 310, 313, 325, 410, 413, 419, 424, 505,5 15, 518, 522, 606, 610, 614, and 617 and each had bed(s), chair(s), night stand(s), chest of drawer(s)/closet space, and a lamp(s) or lights sufficient for reading. Bathrooms were inspected. Water temperature was tested in rooms 127, 135, 210, 213, 220, 225, 313, 413, 505, 515, 518, 522, and 610 and ranged between 105 to 120 degree F. Bathrooms have a working toilet, wash basin, and step-in shower. Bathrooms will accommodate non-ambulatory residents in a wheelchair.
Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Continue to LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198320432
VISIT DATE: 05/30/2025
NARRATIVE
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Adequate supply of linen stored in the laundry room on the fourth and sixth floors and are provided to residents, if necessary.

Emergency Phone Numbers, Exit Plan & Menu:
The facility has a working landline and an after-hours phone line.
There are fire extinguishers located on all floors. Evacuation chairs are in stairway #1 on the first, second, and fourth through sixth floors. Evacuation chairs are in stairway #2 on the fifth and sixth floors only.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a secured kitchen on the first floor. The server door on the first floor contains a lock. Sharp kitchen utensils are also locked in cupboards on the third and fourth floor. Food supply adequate stored in the kitchen area and refrigerator and consists of the following: canned goods, fruit, meat, and vegetables. Emergency food supplies is located in a storage section behind the kitchen area.

Smoke Detectors & Carbon Monoxide Detector:
Los Angeles Fire Department conducted a fire protection equipment performance report on 08/02/2024. The test results revealed passed.

Continue to LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198320432
VISIT DATE: 05/30/2025
NARRATIVE
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Appliances:
The facility is equipped with central air and heat and may be individually adjusted in residents’ room.

Toxins:
Locked/stored outside in a box near generator and in the laundry room near the kitchen area.

Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, and gauze, which are stored in the copy room (first floor), Med rooms (second and fourth floors) and are available for staff use but inaccessible to residents.

Reading Material, Games, Equipment & Materials:
In addition to a monthly activity schedule, the facility has board games, books, arts and crafts, and puzzles for the residents' use, commensurate with the plan of operation.

Pool/Jacuzzi & Pets:
Some residents have pets in their apartments.

Continue to LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198320432
VISIT DATE: 05/30/2025
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Fire clearance:
Fire Clearance with the following special conditions: rooms approved for non-ambulatory/bedridden and approval of delayed egress/secured (locked) perimeter was approved on 11/07/2024. During the facility tour, the delayed egress was tested on the third and fourth floors.

Record Review
Seven (7) staff records were reviewed, 7 out of 7 staff records had required criminal record clearances or criminal record exemptions.
Seven (7) resident records and medications were reviewed.
Infection Control Plan and Emergency Disaster Plan (LIC610E) were reviewed.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

During the prelicensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA by 06/17/2025. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.
Continue to LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: IVY PARK AT PLAYA VISTA
FACILITY NUMBER: 198320432
VISIT DATE: 05/30/2025
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1. During record review, LPA did not observe an Infection Control Plan (last reviewed 04/01/2023) that addressed the initial training requirements for new facility staff, ongoing training requirements for all facility staff, and a description of initial and ongoing training requirements.

2. During record review, LPA did not observe updated CCLD phone numbers, temporary shelter locations, and assignments during an emergency or disaster on the Emergency Disaster Plan (LIC610E). Also, LPA did not observe a key for identifying hospice residents on the register of residents as stated in the LIC610E lasted reviewed 05/04/2023.

3. During facility tour, LPA did not observe a current edition of a first aid manual.

4. During facility tour, LPA did not observe evacuation maps with assembly points.

5. During record review, LPA did not observe an emergency and disaster plan that addresses fire safety precautions specific to evacuation of residents who are bedridden in the event of an emergency or disaster.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to the applicant. An exit interview was conducted, and a copy of this report has been furnished to the applicant.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
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