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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320431
Report Date: 09/30/2026
Date Signed: 09/30/2026 02:57:01 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
05/20/2026 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260520141715
FACILITY NAME:IVY PARK AT PALOS VERDESFACILITY NUMBER:
198320431
ADMINISTRATOR:JOE SALDANAFACILITY TYPE:
740
ADDRESS:25535 HAWTHORNE BLVD.TELEPHONE:
(310) 377-7425
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:115CENSUS: 78DATE:
09/30/2026
UNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Herandy RamirezTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Resident developed a pressure injury while in care.
INVESTIGATION FINDINGS:
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On 09/30/2026, at 10:00am, the department conducted an unannounced subsequent complaint visit to the facility and met with Herandy Ramirez, Business Office Director, and Markeith McGrew, Memory Care Director. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, and deliver findings for the allegation mentioned above.

On 5/28/2026, at 10:15am, the department conducted an initial complaint visit to the facility and was greeted by Neelam Naidu, Regional Health Services Specialist. The department explained the purpose of this visit was to gather facility files, interview staff and residents, and deliver findings for the allegation mentioned above.

The investigation consisted of the following: The department conducted interviews with staff (S1-S3), witnesses (W1-W2), and residents (R2-R8). The department attempted to interview resident (R1) but could not be due to cognitive difficulties. The department received the following documents: Personnel Report, Resident Roster (Dated: 05/28/2026), Medical Assessment (Dated: 06/08/2023, 12/27/2024, 06/12/2024, 05/27/2026)....

Report Continued On LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026
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 3
Control Number 11-AS-20260520141715
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 PALOS VERDES
FACILITY NUMBER: 198320431
VISIT DATE: 09/30/2026
NARRATIVE
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The department reviewed the Hospice Physician Certification of Terminal Illness (Dated: 12/02/2025) and Heartford Hospice Recertification Plan of Care (Dated: 12/27/2024) and observed that the plan is to have the skilled nurse assess exacerbations, comorbidities and other conditions that present themselves while being cared for. Additionally, the skilled nurse was to recognize and intervene to minimize complications, provide comfort care, manage signs and symptoms and collaborate with the Interdisciplinary Group and the resident’s physician. The department observed that the resident received wound care assistance from hospice, when hospice was not at the facility, the caregivers would change any soiled bandages and place a new bandage and advise hospice when it needs to be cleaned, according to staff (S2). The department also observed that a hospice nurse and hospice aides visited the resident several times per week to clean the wound, bathe the resident, and assist with activities of daily living, and medication management. The department observed that the resident is immobile for long periods of time and has underlying medical conditions. The department did not observe any evidence that the staff was negligent in causing the resident to get a pressure injury while in care.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Resident developed a pressure injury while in care. 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, therefore the allegation is Unsubstantiated.

No citations were issued for this complaint investigation.

An exit interview was conducted with Herandy Ramirez, Business Office Director, and a hard copy of this Complaint Investigation Report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20260520141715
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 PALOS VERDES
FACILITY NUMBER: 198320431
VISIT DATE: 09/30/2026
NARRATIVE
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Individual Service Plan (Dated: 01/10/2026), Admission Agreement (Dated: 06/09/2023), Resident Information Sheet (Dated: 05/28/2026), Hospice Physician Certification of Terminal Illness (Dated: 12/02/2025), Heartford Hospice Recertification Plan of Care (Dated: 12/27/2024), Ivy Park at Palos Verdes Charting Notes (Dated: 05/04/2026-05/28/2026), and Healthcare Provider Communication (Dated: 05/07/26-05/19/2026) from the facility.


The investigation revealed the following: Allegation- Resident developed a pressure injury while in care.

The details of the complaint alleged that the resident developed a pressure injury the size of a half dollar coin in the facility due to staff neglect. On 5/28/2026, from 10:30am-2:00pm, the department interviewed staff (S1-S3), witnesses (W1-W2), and residents (R2-R8) regarding the allegation. The department attempted to interview resident (R1) but could not be due to cognitive difficulties. 3 of 3 staff stated that the resident has a history of skin breakdown and is on hospice. Staff also stated that the wound care nurse comes twice per week to clean the wound, in addition to other hospice aides that care for the resident. Staff further stated that the resident is repositioned every two hours to decrease the pressure on the body. Staff denied any neglect in the causing of the pressure wound.

The department interviewed residents (R2-R8) about the allegation and 7 of 7 residents that were interviewed could not corroborate the allegation. The department attempted to interview resident (R1) but could not be due to cognitive difficulties. The majority residents expressed that they have not experienced or witnessed any neglect in care from the staff. The residents stated that the staff checks on them regularly and that they are satisfied with the care they are receiving from the staff. The department interviewed witnesses (W1-W2) and 2 of 2 witnesses that were interviewed stated that the resident is turned every two hours, the wound care nurse comes twice per week, and that they have not noticed any signs of neglect.

The department reviewed the Individual Service Plan (Dated: 01/10/2026) and observed that the facility has a plan of care in place for (R1) that includes total assistance in dressing, hands on assistance in grooming, bathing, eating, toileting, repositioning, and transfer assistance. The department also observed that there was a fall plan in place because the resident is a fall risk. The department reviewed the Medical Assessment (Dated: 06/08/2023, 12/27/2024, 06/12/2024, 05/27/2026) and observed that the resident has a history of skin condition or breakdown. The department observed healthcare provider communication documenting wound care assistance, medication for skin protection throughout the day, and a two hour resident repositioning schedule.

Report Continued On LIC9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3