Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on July 24, 2025, which was clean and showed the facility in good repair with proper medication management and infection control. One complaint investigation in March 2025 substantiated that staff did not respond promptly to residents’ calls for assistance, resulting in falls, which was cited as a deficiency related to resident care and supervision. Other complaint investigations, including those about staffing levels, food service, facility maintenance, and admission agreements, were unsubstantiated. The facility appears to have addressed earlier concerns, as the latest reports show no deficiencies and a well-maintained environment. Several complaint investigations were unsubstantiated, and no fines or enforcement actions were listed in the available reports.
Deficiencies per Year
4
3
2
1
0
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 71
Capacity: 115
Deficiencies: 0
Jul 24, 2025
Visit Reason
An unannounced annual visit was conducted by Licensing Program Analyst Wendy Gibbs to evaluate compliance with licensing requirements at Ivy Park at Palos Verdes.
Findings
The facility was found to be in good repair, clean, and compliant with all applicable regulations. No deficiencies were observed or cited during the visit. Safety equipment, medication management, infection control, and resident accommodations met required standards.
Report Facts
Licensed capacity: 115
Current census: 71
Hospice waiver capacity: 20
Resident rooms inspected: 8
Medication records reviewed: 6
Fire extinguisher last serviced: Dec 3, 2024
Fire prevention inspection date: May 7, 2025
Emergency drill date: Jun 27, 2025
Administrator certificate valid until: Aug 2, 2025
Licensing fees due date: Jul 24, 2025
Freezer temperature: 0
Refrigerator temperature: 45
Water temperature range: Water temperature measured between 108 and 115.4 degrees Fahrenheit
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber Lambert | Business Office Director | Met with Licensing Program Analyst during inspection and exit interview |
| Joe Saldana | Administrator | Administrator certificate validity observed and staff files reviewed |
| Jennifer Frost | Regional Health Services Director | Participated in exit interview |
| Wendy Gibbs | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 115
Deficiencies: 0
May 16, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the licensee does not ensure there are enough staff to meet the needs of residents in care.
Findings
The investigation included interviews with staff, residents, and responsible parties, as well as review of staffing schedules and facility documents. The Licensing Program Analyst observed adequate staffing levels and assistance provided to residents. The allegation was found to be unsubstantiated with no deficiencies cited during the visit.
Complaint Details
The allegation was that the licensee does not ensure enough staff to meet residents' needs, with claims that staff had left and staffing was insufficient. Interviews with staff, residents, and responsible parties indicated sufficient staffing. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Staffing counts: 4
Staffing counts: 4
Staffing counts: 4
Staffing counts: 2
Staffing counts: 4
Staffing counts: 3
Staffing counts: 4
Staffing counts: 2
Staffing counts: 1
Staffing counts: 4
Staffing counts: 3
Staffing counts: 4
Staffing counts: 2
Staffing counts: 1
Staffing counts: 2
Staffing counts: 2
Staffing counts: 2
Staffing counts: 1
Staffing counts: 11
Resident care assignment: 5
Resident care assignment: 7
Resident interviews: 6
Resident interviews: 7
Responsible party interviews: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joe Saldana | Administrator / Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 71
Capacity: 115
Deficiencies: 0
May 1, 2025
Visit Reason
The visit was an unannounced Case Management Visit to follow up on a Special Incident Report and a Death Report related to Resident R1's fall and subsequent passing.
Findings
During the visit, all hallways, walkways, common rooms, and Resident R1's room were observed to be clean, clear, and free of hazards. No health and safety violations were observed. Interviews and document reviews confirmed R1 was a fall risk and that their passing was not related to the fall.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joe Saldana | Administrator | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Wendy Gibbs | Licensing Program Analyst | Conducted the unannounced Case Management Visit and authored the report. |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Capacity: 115
Deficiencies: 1
Mar 13, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-02-12 regarding staff not responding to residents' calls for assistance in a timely manner, resulting in resident falls, and other allegations related to resident care.
Findings
The investigation substantiated the allegation that staff did not respond timely to residents' calls for assistance, resulting in falls for residents R1 and R11. Evidence included pendant device activity reports showing delayed staff response times and incident reports of falls. Another allegation regarding staff taking residents' incontinent supplies was unsubstantiated, as was the allegation that staff do not check on residents every 2 hours.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not respond to residents' calls for assistance in a timely manner, resulting in resident falls. The preponderance of evidence standard was met based on pendant device activity reports, incident reports, staff and resident interviews. Other allegations about staff taking incontinent supplies and not checking on residents every 2 hours were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4): Failure to provide care, supervision, and services that meet individual needs and are delivered by sufficient, qualified, and competent staff. Based on record review, residents R1 and R11 experienced falls after pressing their pendants and waiting an extended period for assistance. | Type B |
Report Facts
Response time to resident pendant calls: 24.55
Response time to resident pendant calls: 23.2
Response time to resident pendant calls: 30.38
Facility capacity: 115
Staff interviewed: 10
Residents interviewed: 8
Witnesses interviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Saladana | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Kelley Koul | Administrator | Facility Administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 115
Deficiencies: 0
Dec 3, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-11-13 regarding allegations that the facility did not refund preadmission fees and did not provide copies of admission agreements.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Records and interviews confirmed that admission agreements were provided to residents and families, and the facility's refund policy was consistent with the admission agreement terms. No deficiencies were observed or cited during the visit.
Complaint Details
The complaint alleged that the facility did not refund preadmission fees to resident R1 and did not provide copies of the admission agreement to the family. The investigation reviewed relevant documents and interviewed staff and residents, concluding the allegations were unsubstantiated due to lack of evidence.
Report Facts
Capacity: 115
Census: 69
Complaint control number: 11-AS-20241113145950
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation |
| Kathleen Olson | Regional Operations Specialist | Met with during the inspection and exit interview |
| Kelley Koul | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 115
Deficiencies: 0
Nov 26, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff threatened a resident with eviction, did not properly maintain the facility, and did not provide adequate food service.
Findings
The investigation found no sufficient evidence to support the allegations. Interviews with the administrator, staff, and residents, as well as records and facility inspections, indicated that the facility was properly maintained, food service was adequate, and no threats of eviction occurred. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff threatened a resident with eviction, did not properly maintain the facility, and did not provide adequate food service. The investigation included interviews with the administrator, staff, and residents, review of records including Special Incident Reports and menus, and a health and safety check of the facility. The allegations were found to be unsubstantiated.
Report Facts
Capacity: 115
Census: 69
Resident rooms inspected: 4
Weeks of menu reviewed: 7
Staff interviewed: 6
Residents interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Kelley Koul | Administrator | Facility administrator interviewed during investigation |
| Kristal Jenkins | Interim Executive Director | Met with Licensing Program Analyst during inspection and received the complaint report |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 115
Deficiencies: 0
Sep 13, 2024
Visit Reason
An unannounced case management visit was conducted due to two Special Incident Reports regarding resident falls submitted on 08/30/24 and 09/02/24.
Findings
The Licensing Program Analyst toured the facility and found all walkways, hallways, common rooms, and resident rooms clean, clear, and free of hazards with ample lighting. No health and safety violations were observed during the visit.
Complaint Details
The visit was triggered by two resident falls resulting in fractures; Resident R1 had a right distal radius fracture and Resident R2 had a right subtrochanteric fracture requiring surgery. Resident R1 does not have a fall plan, and Resident R2 is considered a fall risk due to medical diagnosis.
Report Facts
Facility capacity: 115
Resident census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the unannounced case management visit |
| Krystal Jenkins | Regional Operations Specialist | Met with Licensing Program Analyst during the visit and exit interview |
| Kelley Koul | Administrator/Director | Facility Administrator/Director |
Inspection Report
Original Licensing
Census: 77
Capacity: 115
Deficiencies: 0
Jul 2, 2024
Visit Reason
The visit was an announced pre-licensing inspection conducted to evaluate the facility for a change of ownership application submitted on 2023-10-20.
Findings
The facility was found to be clean, well-maintained, and in good repair with all safety systems operable. No issues requiring corrections were observed during the visit.
Report Facts
Licensed capacity: 115
Census: 77
Non-ambulatory residents allowed: 107
Bedridden residents allowed: 8
Freezer temperature: 0
Refrigerator temperature: 45
Water temperature range: 113.3-117.5
Fire extinguisher last serviced: May 17, 2024
Fire safety inspection date: May 14, 2024
Last emergency drill date: Jun 28, 2024
Perishable food supply: 3
Nonperishable food supply: 7
Facility temperature: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelley Koul | Administrator | Met with Licensing Program Analysts during the inspection and participated in exit interview |
| Wendy Gibbs | Licensing Program Analyst | Conducted the pre-licensing visit and signed the report |
| Perry Scott | Licensing Program Analyst | Conducted the pre-licensing visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
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