198320432-12-12-2025-11-AS-UCOL-DPNQ3J-20251224104849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320432
Report Date: 12/12/2025
Date Signed: 12/12/2025 03:11:10 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 VISTA		FACILITY NUMBER:	198320432
ADMINISTRATOR:	ELIGIO, NESTOR		FACILITY TYPE:	740
ADDRESS:	5555 PLAYA VISTA DRIVE		TELEPHONE:	(310) 437-7178
CITY:	PLAYA VISTA	STATE: CA	ZIP CODE:	90094
CAPACITY:	102	CENSUS: 70	DATE:	12/12/2025
		UNANNOUNCED	TIME BEGAN:	08:31 AM
MET WITH:	Dina Davis		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not answer resident's calls for assistance timely.
Staff gave resident incorrect medications.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/12/2025, 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. Continue to LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025

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-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: 12/12/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 12/12/25, LPA interview Staff #2, #10, and reviewed R1’s Physician’s Orders and Hospitalization Discharge Records.

Regarding the allegation, “Staff do not answer resident's calls for assistance timely,” it is being alleged Resident #1 (R1) did not get timely assistance between 05/04/25 – 05/11/25, 06/29/25 – 07/01/25, 09/11/25 – 09/13/25, 10/19/25 – 10/23/25, and 10/27/25 – 10/28/25. It is also alleged that the October delays resulted in R1 urinating on self.

Record review of R1’s assessment (06/12/25) revealed R1 requires toileting schedule with stand-by assistance for incontinence episodes. Full care. Record review of R1’s call system (05/09/25) revealed zero out of three calls were responded to after 15 minutes. Record review of R1’s call system (05/10/25) revealed one out of seven calls were responded to after 15 minutes. Record review of R1’s call system (05/11/25) revealed two out of four calls were responded to after 15 minutes. Record review of R1’s call system (06/29/25) revealed three out of eighteen calls were responded to after 15 minutes. One call was “forced complete”. Record review of R1’s call system (06/30/25) revealed one out of thirteen calls were responded to after 15 minutes. Record review of R1’s call system (07/01/25) revealed four out of fourteen calls were responded to after 15 minutes. Record review of R1’s call system (09/12/25) revealed zero out of four calls were responded to after 15 minutes. Three calls were “forced complete”. Record review of R1’s call system (09/13/25) revealed zero out of five calls were responded to after 15 minutes. Three calls were “forced complete”.

Record review of R1’s call system (10/19/25) revealed one out of five calls were responded to after 15 minutes. Two calls were “forced complete”. Record review of R1’s call system (10/20/25) revealed two out of eleven calls were responded to after 15 minutes. Four calls were “forced complete”. Record review of R1’s call system (10/21/25) revealed one out of tens calls were responded to after 15 minutes. Two calls were “forced complete”. Record review of R1’s call system (10/22/25) revealed one out of eight calls were responded to after 15 minutes. Seven calls were “forced complete”. Record review of R1’s call system (10/23/25) revealed one out of six calls were responded to after 15 minutes. Four calls were “forced complete”. Record review of R1’s call system (10/27/25) revealed four out of eight calls were responded to within 15 minutes. Four of the calls were “forced complete”. Record review of R1’s call system (10/28/25) revealed three out of five calls were responded to after 15 minutes. Continue to LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025

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: 12/12/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff #5 indicated that “force complete” occurs when a care staff is having technical issues with resetting the call button and the front desk completes the call. Five out of five staff interviews (S2 – S5, S7) indicated staff responds to calls within 5 – 15 minutes. S2 provided explanation for the calls answered after 15 minutes. Staff shortage on 05/10/25 – 05/11/25. Staff was delivering tray services and R1 was in the dining room waiting to be escorted upstairs (07/01/25 8:51 AM). Staff was delivering tray services and R1 was waiting to come downstairs for lunch (07/01/25 11:56 AM). Care Providers were providing care to other residents (10/22/25 1:38 PM). R1 called during the middle of crossover in which Care Providers and Medtechs meet to give resident updates (10/23/25 1:51 PM and 1:54 PM). R1 made a pendant call and it was not cleared because some staff do not have a pendant or the internet signal was not strong. Thus, staff waited for the concierge to clear the call (10/21/25 and 10/28/25 7:13 AM). S2 indicated that none of the delays resulted in R1 urinating on self.

R1 indicated that it can take 10 – 40 minutes for staff to respond to calls. R1 indicated that the morning shift is the longest. Four out of five residents indicated (R2, R8 – R11) that staff responds after 15 minutes. R12 has not used the call system.

Regarding the allegation, “Staff do not answer resident's calls for assistance timely,” based on record review 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.

Allegation: Staff gave resident incorrect medications

Record review of Medication Administration Records (June – October 2025) do not reveal that R1 was given incorrect medication. Two out of two staff interviews (S4, S7) indicated there has not been any medication errors nor complaints. S3 and S5 indicated that staff has been issuing R1’s medication according to the physician’s order on file. S2 indicated R1 has not made medication complaints but refuses one specific medication.

R1 indicated that R1 is taking too much medication. R9 and R11 manages own medication. Four out of four residents indicated (R2, R8, R10, R12) that medication is given according to physician’s orders. Continue to LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025

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: 12/12/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation, “Staff gave resident incorrect medications,” 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.

No deficiencies cited.

An exit interview was conducted and a copy of this report was provided to the Executive Director Dina Davis.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4