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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320432
Report Date: 12/11/2025
Date Signed: 12/11/2025 04:53:41 PM

Unsubstantiated


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
10/28/2025 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20251028145616

FACILITY NAME:IVY PARK AT PLAYA VISTAFACILITY NUMBER:
198320432
ADMINISTRATOR:ELIGIO, NESTORFACILITY TYPE:
740
ADDRESS:5555 PLAYA VISTA DRIVETELEPHONE:
(310) 437-7178
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY:102CENSUS: 68DATE:
12/11/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Dina DavisTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Staff did not ensure resident received meals.
Staff did not ensure resident was getting showers.
INVESTIGATION FINDINGS:
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4
5
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7
8
9
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12
13
On 12/11/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Executive Director Dina Davis and the purpose of the visit was explained.

Investigation consisted of the following: On 11/06/2025, LPA obtained Personnel Report, Register of Residents (Updated 11/05/25), R1 – R3’s Admission Agreement, Resident Assessment, Individualized Service Plan, Staff Assignment (November 2025), R1 – R3 and R7’s Medication Administration Record (05/2025 – 10/2025), Signal Call Logs (05/04/25 – 05/11/25, 06/29/25 – 07/01/25, 09/11/25 – 09/13/25, 10/19/25 – 10/23/25,10/27/25 – 10/28/25), reviewed seven resident records (R1 – R7), and Physician’s Orders (R1 – R2). LPA interviewed Staff #2 – 7 and Residents 1 – 2, 8, 9, 10, 11, 12. On 11/07/25, LPA received work schedule (05/10/25 – 05/11/25,06/29/25, 10/20/25 – 10/23/25, 10/27/25 – 10/28/25). On 12/11/25, LPA received R1’s August 2025 ledger. On 12/11/25, LPA interviewed Staff #2, #3, #8, and #9 and reviewed R1’s Physician’s Orders and staff work schedule.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20251028145616
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 PLAYA VISTA
FACILITY NUMBER: 198320432
VISIT DATE: 12/11/2025
NARRATIVE
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Regarding the allegation, “Staff did not ensure resident received meals,” it is being alleged that Resident #1 (R1) meals were delayed or missed in August 2025. Record review of R1’s August 2025 ledger revealed tray services charges from 08/01/25 – 08/08/25. Three out of three staff interviews (S2 – S4) indicated that the care staff monitor that resident receive their meals. Interview with the Executive Chef (S6) indicated that R1 has not made any complaints. Staff #7 indicated R1 has not had tray service complaints and has meals downstairs. S2 indicated R1 received tray services a couple of times due to illness but usually eats downstairs by the second day. R1 has also complained about it not arriving on time but tray services are delivered to the first, second, fifth, and sixth floors respectively. R1 indicated that R1 eats downstairs but has received tray services. R1 indicated that the food quality for tray services was not very good. Five out of five residents indicated (R8 – R12) that eats downstairs. Resident #2 indicated that tray services were received on time.

Regarding the allegation, “Staff did not ensure resident received meals,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

Regarding the allegation, “Staff did not ensure resident was getting showers,” it is being alleged Resident #1 (R1) did not receive showers according to the plan of care in August 2025 and between 10/22/25 – 10/23/25. It is alleged that R1 is on an every-other-day shower schedule. Record review of R1’s Resident Assessment (06/12/25) revealed R1 requires total assistance for all showering/bathing needs 4x/week. Record review of R1’s Resident Assessment (10/31/25) revealed R1 requires total assistance for all showering/bathing needs 1-2x/week. Four out of four staff interviews (S4 - S7) indicated there has not been any shower complaints. S2 indicated that R1’s showers increased from twice per week to four times per week (Sunday, Tuesday, Thursday, and Friday). Executive Director indicated that R1 is receiving four showers at the standard rate (two showers). R1 indicated that showers are given according to the agreement; however, there were issues in the past because staff did not want to give showers to R1. R1 indicated that things got better. Two out of two residents indicated (R2, R11) that showers are given according to agreement. R8 – R10, R12 are independent.

Regarding the allegation, “Staff did not ensure resident was getting showers,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Continue to LIC9099-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20251028145616
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 PLAYA VISTA
FACILITY NUMBER: 198320432
VISIT DATE: 12/11/2025
NARRATIVE
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3
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5
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32
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiencies cited.

An exit interview was conducted and a copy of this report was provided to Dina Davis.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4