Ivy Park At San Marino

Allegation investigated: Resident sustained multiple severe pressure injuries due to staff neglect.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit for the allegation listed above. LPA met with Administrator Kimberly Sanchez, and was informed the reason for the visit. The investigation consisted of the following: On 7/1/25, LPA De Leon conducted a 24-hour health and safety inspection. LPA conducted a physical plant tour on both first and second floor and did not observe any immediate health and safety concerns. LPA also requested copies of the staff roster, resident roster, and collected documents for Resident 1 (R1). On 10/6/25, LPA interviewed the Executive Director, three staff, and two residents. LPA gathered additional documents for Resident #1 and requested for the Home Health Agency documents. During the visit today, LPA Chan interviewed two additional staff and four residents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 3, 2025 · control 28-AS-20250630101215

Allegation investigated: Staff left resident on the ground for an extended period of time. Staff are refusing to lift resident back up off the floor.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the allegations listed above. The purpose of the visit was explained to Kimberly Sanchez. The investigation consisted of: A physical plant tour of the facility was conducted. Special focus of the Memory Care Unit operations was observed. A total of 7 staff and 9 residents were interviewed. Resident (R1's) file was reviewed. Copies of R1's Face Sheet, Physician's Report, Individualized Service Plan, Resident Assessment and charting notes were obtained. In addition, medical emergencies-calling 911 policy, Dementia Care Plan, fall incident reports in the last month, resident roster, and staff roster were obtained. *Note an incident report for the alleged incident was not submitted to CCLD within 7 days. A case management report was generated to issue a citation for reporting requirements. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 31, 2025 · control 28-AS-20251024145312

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff did not address change in resident's condition. Facility staff did not ensure the call button in resident's room worked. Facility staff did not ensure residents' had clean clothing to wear.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations. The purpose of the visit was discussed with Health Services Director Leticia Garcia. The investigation consisted of: On 7/15/25, the facility signal system and pendant buttons were tested in 22 rooms. All room signal systems in the Memory Care Unit were tested. Record review, physical plant inspection, and interviews with staff (S1- S6) was conducted. Deceased resident (R1's) records were collected. On 10/9/25, record review of additional documents, physical plant inspection, signal room testing of 20 rooms, and interview with Executive Director was completed. During today's visit seven (7) residents were interviewed. No health and safety concerns were observed during the visits. *Narrative continues next page. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 16, 2025 · control 28-AS-20250708145439

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are mismanaging resident's medication.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the allegation listed above. The purpose of the visit was explained to Health Services Director Leticia Garcia. The investigation consisted of: The physical plant was toured, records were reviewed, and interviews with residents (R1-R9) and staff (S1-S4) was conducted. Resident (R1's) file documents were obtained. Copies of Copies of R1's Face Sheet, Physician's Report, Individual Service Plan, 2 medication physician orders dated 5/30/25, QuickMar charting notes, Medication Administration Records for months May 2025- June 2025, resident roster, and staff roster were obtained. No health and safety concerns were observed. *See next page. Substantiatedthe state’s words, verbatim · CDSS document, Jun 19, 2025 · control 28-AS-20250616090026

Allegation investigated: Staff did not allow resident in care to communicate with their family member.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the allegation listed above. The purpose of the visit was explained to Executive Director Kimberly Sanchez. The investigation consisted of: LPA toured the Memory Care Unit and Assisted Living was conducted. Residents (R1- R7), staff (S1- S6), and two (2) family members were interviewed. Resident (R1's) file was reviewed. Copies of R1's Face Sheet, Physician's Report, Appraisals, Power of Attorney, Advance Health Care Directive, staff roster, and resident roster were obtained. No health and safety concerns were observed. **See page 2. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 1, 2025 · control 28-AS-20250430084256

Allegation investigated: Questionable Death. Licensee is not ensuring that resident's records are provided to resident's responsible party as necessary.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations. The purpose of the visit was discussed with Executive Director Kimberly Sanchez. The investigation consisted of: On 1/22/2025, a physical plant inspection of the facility was conducted. Staff (S1- S3) were interviewed, and deceased resident's (R1) records were collected. Documents collected: Move-In Record/ Face Sheet, Admission Agreement, Physician's Report, Advance Health Care Directive, PointClickCare Notes, incident report (8/15/24), death report, POLST, DNR, and staff and resident rosters were obtained. During the course of the investigation, LA County Death Certificate was obtained. R1's authorized represemtative was contacted today and record review was completed. No health and safety issues were observed. *See 9099C. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 17, 2025 · control 28-AS-20250121095720

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.