Ivy Terrace At Garden Grove

Allegation investigated: Lack of supervision resulted in resident sustaining serious injuries Lack of supervision resulted in resident sustaining multiple falls

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator (AD) Leah Gutierrez and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed AD, witnesses, and staff, and obtained and reviewed records, including resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated April 5, 2023, R1’s care plan dated March 19, 2024, R1’s charting notes dated April 24, 2023 to December 15, 2024. R1’s incident reports from November 12, 2024, and December 6, 2024. R1’s certificate of death dated December 18, 2024. R1’s hospice nursing assessment dated December 9, 2024. R1’s hospice admission form. R1’s hospice safety and fall risk assessment dated December 9, 2024. R1’s hospice medication list for December 2024. R1’s physician’s orders dated December 9, 2024. R1’s hospithe state’s words, verbatim · CDSS document, Apr 22, 2026 · control 22-AS-20241220151126

Allegation investigated: Staff did not safeguard a resident's personal belongings Staff did not respond to call system Call system is not operational

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA was greeted and granted entry and explained the reason for the visit. During the course of the investigation, LPA toured the memory care unit and interviewed staff as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegations that staff did not safeguard a resident's personal belongings, staff did not respond to call system and call system is not operational, the investigation revealed the following: Resident laundering is as follows: AM/ PM shift caregivers wash clothing and NOC shift puts clothing away. Five out of five staff state residents clothing turns up missing on occasion due to names not being on clothing or the status of the residents. Staff confirm Resident 1(R1) had missing items. Staff 1 (S1) states being aware of an incident reported regarding Resident 1's (R1) clothing being misthe state’s words, verbatim · CDSS document, Sep 26, 2025 · control 22-AS-20250613141313

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

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

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 are not meeting clients dietary needs Staff are not properly addressing pest infestation in facility Facility staff are not keeping the facility at a comfortable temperature for residents

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and resident as well as reviewed and obtained pertinent documentation such as facility menu. Regarding the allegations that facility staff are not meeting clients dietary needs, facility staff are not keeping the facility at a comfortable temperature for resident and staff are not properly addressing pest infestation in facility, the investigation revealed the following: Resident 1 (R1) has an order for double portions at meal time and confirms receiving double portions. R1 stated dissatisfaction with certain meals while admitting there are other choices to choose from if the main meal is not to the resident's liking. Two out of two staff confirm resident receives doubthe state’s words, verbatim · CDSS document, Oct 15, 2024 · control 22-AS-20241007161459

Allegation investigated: Staff did not provide transportation to resident Staff mishandled resident medications Resident did not receive medication as prescribed

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA toured the facility and interviewed staff and resident as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegations that resident did not receive medication as prescribed, staff mishandled resident medications and staff did not provide transportation to resident, the investigation revealed the following: When Resident 1 (R1) admitted into the facility on 10/20/2023, resident was not prescribed phenobarbital. Resident confirms admitting into facility without the prescription for phenobarbital. Resident admitted into the facility post skilled rehab. Resident was prescribed phenobarbital 100mg 1/2 tab twice daily effective 01/15/2024. The prescription was adjusted effective 08/30/2024 to 60mg 1 tab twice daily. LPA audited the resident's medications during the visit and medications are being admthe state’s words, verbatim · CDSS document, Sep 17, 2024 · control 22-AS-20240913154738

Allegation investigated: Lack of supervision resulting in resident sustaining multiple falls Lack of supervision of resident resulting in a hip fracture

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the two allegations listed above. LPA was greeted and granted entry by facility administrator Darlene Lopez after stating the reason for the visit and listing the allegations. An initial complaint investigation visit was conducted on December 19, 2023. LPA reviewed resident records for resident R1 including the physician report established upon admission in October 2020, the updated medical assessment dated March 23, 2023 as well as documents related to medication prescription, hospice admission after August 2023 and an admission at Los Alamitos Medical Center from December 8, 2023 until December 12, 2023 during which R1 received surgery for a hip fracture. Additional records were requested from Los Alamitos Medical Center via subpoena on January 11, 2024. CONTINUED ON FORM LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 11, 2024 · control 22-AS-20231212161617