Ivy Cottages II

Type of visit: Required - 1 Year

On June 11, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purposes of conducting a required 1-Year annual visit using the CARE Inspection Tool. LPA Bentley was greeted and granted entry into the facility by staff, after stating the reason for the visit. Administrator (Admin) Carmen Rodriguez arrived shortly to assist with the visit. The facility is licensed to operate age 60 and over for (6) non-ambulatory residents, with a Hospice waiver for three (3). The building is a single story structure located in a residential neighborhood, which consists of the following: six (6) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living area, dining area, kitchen, an outdoor covered seating areas, and an attached two car garage. LPA Bentley toured the inside and outside of the physical plant with Admin. There were no bodies of water or obstructions on the premises. All rooms were inspected and the facility was observed to be appropriately furnished at the time of visit. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Additional linens, comforters, and bath towels were adequately stocked and available. Bathrooms were found to be clean and operational with water temperatures measured between 111.7 degrees F to 114. degrees F. The kitchen was observed clean and there is a two-day supply of perishable and seven-day supply of non-perishable food available. Toxins, disinfectants, sharps, and medications were secured and inaccessible to residents in care. One out of four stove burners was observed non-operational. A deficiency is being cited. CONTINUE TO LIC809-C PAGE..... The fireplace was covered with a screen and secure. The garage and backyard were observed free of clutter and debris and the facility has one exit gate that was operational. The smoke alarms and carbon monoxide detectors were operable. An emergency safety drill was last conducted on June 5, 2026 and are conducted quarterly. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has two (2) fire extinguishers that were charged, mounted, and serviced on August 12, 2025. First aid kit is maintained and contains all the necessary elements. A working telephone (714-531-2185) remains available and the facility has a device that can be used for video teleconference purposes. LPA Bentley conducted an audit of six (6) resident files (R1-R6), four (4) staff files (S1-S4), and medication and medication administration records review were all found in order and complete. Interviews were conducted with staff and residents. Liability Insurance is effective April 30, 2026 and expires on April 30, 2027. Based on today’s observations, a deficiency is cited during the visit, per Title 22, Division 6, Chapter 8 of the California Code of Regulations. An exit interview was conducted with Administrator Carmen Rodriguez, and a copy of this report, LIC809-D, and appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jun 11, 2026

Allegation investigated: Staff did not seek timely medical care for resident in care Staff did not provide adequate food service to residents in care Staff did not provide activities to residents in care

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA was greeted and granted entry by staff at 8am. LPA met with Licensee (LE) Carmen Rodriguez and explained the purpose of the visit. LPA obtained the following documentation for Resident #1 (R1): Emergency and Identification Information, Physician's Report dated 11/27/2023, Appraisal Needs and Services Plan dated 4/20/2024, Preplacement Appraisal Information dated 4/20/2024, Admissions Agreement and Durable Power of Attorney for Finances and Property. Upon entry LPA observed there were six residents and four staff members present. Two staff members were preparing residents for the day and providing showers. Two staff members were preparing breakfast and feeding residents. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) LPA interviewed two of two staff members who were present in 2024 and two of three residents who resided in the facility in 2024. LPA also attempted to contact three of three witnesses and was unable to contact any of the witnesses. It was alleged that: Staff did not seek timely medical care for resident in care. LPA interviewed two of two staff regarding the services provided to Resident #1 (R1). R1 moved into the facility from a large assisted living on May 20. 2024. R1 was non-verbal and, per Physician's Report dated November 27, 2023, R1's diagnosis was Major Neurocognitive Disorder. No skin lesions or wounds were noted on May 20, 2024. Per interview of two of two staff, R1 only had a pink rash but there was no puncturing of the skin. Two of two staff stated they were working on obtaining physical therapy (PT) and occupational therapy (OT) for R1 through insurance but resident passed away seventeen days later. R1 passed away on May 6, 2024 due to cardiac arrest. Fountain Valley Police Department had arrived on scene with paramedics and a photo was taken of the Electrocardiogram that was on file with the date of May 6, 2024 at 1:59pm. Two of two staff denied the allegations that the facility did not seek timely medical care of R1. Two of three residents interviewed stated they do not have issues with the care being provided. LPA observed the medications and nitroglycerin was provided to the facility upon discharge from the larger assisted living facility. Nitroglycerin was prescribed as needed. Per interview with staff, nitroglycerin was not administered due to the immediate arrival of paramedics; whose proximity is very close the facility. LPA investigated the allegation that: Staff did not provide adequate food service to residents in care. LPA toured the facility with Licensee (LE) and observed two staff members preparing and feeding breakfast to residents in care. Breakfast consisted of fruit, yogurt, pancakes and oatmeal. Lunch was being prepared in a slow cooker and consisted of pork roast, carrots and potatoes with salad. LPA observed a baked cake prepared on May 11, 2026 for the residents. The pantry had seven days of non-perishable items and the refrigerator had two days of perishable items. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) Interviews with two of two staff stated that R1's spouse visited once or twice a week per Dial-a-Ride and would arrive between 1-2pm. Staff stated R1 would eat approximately 25% of food. Spouse wanted R1 to eat more food but R1 was not responsive to eating an entire meal. Interviews of two of three residents stated they are being fed plenty of food and that they like the food. It was also alleged that Staff did not provide activities to residents in care. LPA interviewed two of three residents who answered that they participate in activities. Two of two staff also shared with LPA that for the past twenty years, a piano person comes on Thursdays and plays music for the house for approximately one hour. Residents take a daily walk around the block. During the visit LPA observed staff with the six residents in a circle, doing a ball toss and exercise. Two of two staff reported that when family came to visit R1, it was always after lunch when residents took a nap. Most of the activities occur in the morning between breakfast and lunch. LPA observed various types of activities throughout the facility for staff to engage residents. Two of three residents interviewed participate in activities and liked dancing and music. Later in the afternoon, prior to dinner, activities resumed but family was not present at this time and wanted activities to occur while residents were napping. Based on LPA's observations, interviews and record review, the allegations that: Staff did not seek timely medical care for resident in care, Staff did not provide adequate food service to residents in care and Staff did not provide activities to residents in care are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Licensee (LE) Carmen Rodriguez, and a copy of this report and LIC 811 was provided to the facility.the state’s words, verbatim · CDSS document, May 12, 2026 · control 22-AS-20240529100646

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Ricardo Peralta. Administrator (AD) Carmen Rodriguez arrived shortly after. For today’s visit, LPA observed a total of six residents in care and three staff members on duty. During today's visit LPA observed the AD certificate for AD Carmen Rodriguez which expires on May 21, 2026. LPA toured the interior and exterior portions of the facility with AD. The facility is a one story structure and is licensed for six non-ambulatory residents, of which four may be on hospice and zero bedridden. There are a total of seven bedrooms, of which six are resident bedrooms and one staff bedroom. LPA toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of three restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 108.3-109.0 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged and one was located by the kitchen and one in the garage. During today's visit LPA observed the residents eating chicken with vegetables, mash potatoes, salad and fruit for lunch. CONTINUED ON LIC809-C... LPA observed the emergency disaster and evacuation plan which is located by entryway. Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care. The medications are locked in a cabinet by the kitchen. For the exterior portion, LPA observed a shaded area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard, which is both is self-closing and self-latching. No bodies of water were observed. LPA reviewed six resident files and three staff files. LPA interviewed residents and staff present. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. LPA advised AD to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA. An exit interview was conducted with AD Rodriguez. A copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Dec 17, 2024