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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602608
Report Date: 07/29/2025
Date Signed: 07/29/2025 04:25:15 PM

Document Has Been Signed on 07/29/2025 04:25 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:IVY PARK AT CERRITOSFACILITY NUMBER:
198602608
ADMINISTRATOR/
DIRECTOR:		LAURA RODRIGUEZFACILITY TYPE:
740
ADDRESS:11000 NEW FALCON WAYTELEPHONE:
(562) 865-9500
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 163CENSUS: 137DATE:
07/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Carmen Hernandez, Business Office ManagerTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted the unannounced required annual inspection. LPA met with the Business Office Manager, Carmen Hernandez and the purpose for the visit was explained. The facility is licensed for the age range 60 and over and 163 non-ambulatory residents. Currently, the facility has six (6) hospice waiver residents and seven (7) home health residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control Plan: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan in place.

Physical Plant and Environmental Safety: LPA toured the facility with the Business Office Manager, Carmen Rodriguez. This property is comprised of one large two-story building on 5.5 acres and contains (90) studio apartments, (42) - 1-bedroom apartments, (12) 2- bedroom apartments, first floor; Lobby/Front desk reception area, administrative offices, Computer room, Salon, Coffee Lounge, Dining room, Kitchen, Community Laundry room, Housekeeping Storage closet, Men/Women restroom, (2) utility rooms. Second floor; Program Director office, Director of Nursing office, Staffing Coordinator office, Medication room, Library, Fitness Center, Theater/Multipurpose room, Men/Women restroom, (4) utility rooms, Storage room (emergency food supplies) and (PPE supplies). The outdoor grounds contained bodies of water in a fountain,
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: IVY PARK AT CERRITOS
FACILITY NUMBER: 198602608
VISIT DATE: 07/29/2025
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Physical Plant and Environmental Safety [Cont.]: East Wing Courtyard, West Wing Courtyard and community park. Passageways, walkways, and patios are free from obstructions and hazards. The facility is equipped with central air and heat. LPA inspected 14 residents' rooms and each resident bedroom has the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid matt/strips and shower chair. The temperature measured between 110.0 and 117.0-degrees F which is within the Title 22 regulation. The carbon monoxide detectors and smoke detectors are interconnected and all tested and they are all working well. Fire Extinguishers are fully charged.

Resident Rights-Information: LPA observed the required posters posted in the facility which include Long Term Care Ombudsman located on the second floor next to the resident's laundry room, and the Community Care Licensing Complaint and Personal Right Poster are located on the first floor near the resident's mailbox. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physicians.

Planned Activity: Facility has sufficient space to accommodate for indoor and outdoor activity. LPA also observed the weekly activity calendar and it's posted in the facility. The facility does have an active Resident Council.

Food Service: Currently the facility has about three (3) residents who are required to go on modified diet and LPA reviewed and observed the doctor's order. The facility has an ample supply for two days perishable and seven days non-perishable food supply. The facility also has emergency food supplies and water located on the first floor. All the food are stored properly. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked. Walls and floors, cabinets and counters were clean and sanitary throughout the facility.

Incidental Medical and Dental: LPA reviewed 14 centrally stored resident medications; containing a 30-day supply of medications and no issues were observed. Medical and dental transportation is provided if needed.


NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: IVY PARK AT CERRITOS
FACILITY NUMBER: 198602608
VISIT DATE: 07/29/2025
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Disaster Preparedness: The facility has an updated LIC610E Emergency Disaster Plan. The facility has two alternative shelter location for emergencies. The last fire /disaster drill was conducted on 7/23/2025. LPA also observed the evacuation chair at each stairwell.

Due to time constraints, LPA will return at a later date to complete five (5) CARE Tool domains.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. An exit interview was conducted and a copy of the report was provided to the Business Office Manager, Carmen Hernandez.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
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