Ivy Park at San Juan Capistrano

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Allegation investigated: Staff makes inappropriate comments towards residents.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of continuing the investigation into the above allegation. LPA met with Executive Director Kyle Coleman and explained the reason for the visit and discussed the allegations. During the course of the investigation, LPA conducted a review of the medications and interviewed seven residents and five staff. Copies of documents pertinent to the allegation was obtained for review: Resident Rosters, Personnel Reports, Staff Contact Information, Face Sheets, Physician's Reports, medication cycle report, and Medication Administration Records. The investigation revealed the following: Regarding the allegation, Staff makes inappropriate comments towards residents, it is alleged that Staff #1 (S1) would roll their eyes in response to residents' queries and state that their time is being taken away from helping another resident causing residents to feel uncomfortable asking for help. Based on the interviews, six of seven residents and three of five staff denied the allegation concerning S1 and any other staff. Unsubstantiated Both bottles had a quantity of 60 pills per the prescription labels opened on January 21, 2024. LPA reviewed and counted the remaining tablets twice. There were 13 tablets remaining for the Sprinolactone 100mg and 14 tablets remaining for the Spironolactone 50mg. It was documented on the MAR that R1 received both medications daily in February and March 2024 even though the 100mg bottle had one less tablet. Neither MAR nor the Med Pass Exceptions did not indicate that the medications were refused or not taken from January to March 2024 which corroborates facility failed to properly manage the medications. Therefore, the preponderance of evidence standard has been met. A deficiency is being cited on the attached LIC9099-D. An exit interview was conducted with Executive Director Kyle Coleman, and a copy of this report including the appeal rights were provided at the end of the visit. One resident indicated having a limited interaction with S1 and did not experience any eye-rolling or negative attitude, however the two staff witnessed S1 rolling their eyes. The one resident and both staff confirmed that S1 did not appear interested or engaged and did not provide assistance to residents. Based on the interviews, there were no clear details to corroborate the allegation. Therefore, based on interviews which were conducted, 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 following allegation: Staff makes inappropriate comments towards residents is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Kyle Coleman, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, May 18, 2026 · control 22-AS-20240227144455

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 25, 2026

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Based on the review of the medications, the licensee did not ensure R1 received assistance with one medication, Spirinolactone, by not administering R1's prescribed medication per the doctor's order which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, May 18, 2026

Plan of correction: ED Coleman stated that medication staff will be retrained on ensuring residents receive their medications as prescribed and properly completing the Medication Administration Record and will submit proof to LPA by POC due date.

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry after introducing himself and the purpose of the visit to front desk staff. Executive Director David Alvarado was notified of the visit and was also present on the premises. LPA requested and reviewed the facility's resident census, staff roster, Emergency and Disaster Plan, Infection Control Plan, staff records including initial and annual training records from Relias. A sample of ten staff records and ten resident records were reviewed during the visit. There are 76 residents admitted at the time of the visit, four of which are receiving hospice care. Resident and staff records were confirmed to include all necessary components per Title 22 regulations. The facility is a two-story building organized around multiple courtyards. LPA accompanied by administrator conducted a tour of the interior and exterior of the physical plant. A total of nine units out of a total of 89 were visited and reviewed throughout the facility. Rooms were observed to be equipped with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Bathrooms were observed to be in good repair; and provided with grab bars and clean slip mats. Hot water was measured in a total of nine locations at faucets delivering hot water for grooming purposes. Water was systematically observed to be within the acceptable temperature range, ranging from 106F to 112F. LPA and staff additionally toured the facility kitchen. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Emergency food and water supply observed in the additional dry food storage with expiration dates current. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 No unsecured medications, cleaning supplies, or sharp items were observed during the walk-through. There are 43 residents on medication management. Medical assessments were verified to indicate whether residents managing their own medications were safe to do so. No discrepancies observed. Prescriptions and medication on hand verified for four randomly picked residents, two of which are receiving hospice care at the time of the visit. There are two secure medication carts on the premises, one assigned to each level of the building. Sprinkler system and fire safety systems were inspected on September 17, 2025. Fire extinguishers have been maintained adequately. For the exterior portion, facility has a one courtyard on each side. The routes of egress were free of tripping hazards and the exit gates were self-latching and functional. Proof of current liability insurance provided and reviewed. Shade and outdoor furniture verified to be present. Based on the observations conducted on this day, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 25, 2025

Allegation investigated: Staff are not criminally record cleared

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director (ED) David Alvarado and explained the reason for the visit. The investigation revealed the following. LPA and the Executive Director toured the facility. At the time of the visit LPA observed 16 staff members. LPA verified all 16 staff members are background cleared and associated to the facility. LPA interviewed 5 staff members. The Executive Director reported that all staff members required to have a criminal background clearance have one and are associated to the facility. LPA did not observe any staff members who were not background cleared and associated to the facility. LPA reviewed the staff roster and verified the staff members on the roster are background cleared and associated to the facility. Based on the evidence gathered the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided. Unfoundedthe state’s words, verbatim · CDSS document, Jul 17, 2025 · control 22-AS-20250716082936

Allegation investigated: Staff did not ensure residents light worked properly Staff do not ensure medications are properly managed for residents in care

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegations listed above. LPA met with Executive Director David Alvarado and explained the reason for the visit. The investigation into the allegation, staff did not ensure resident's light worked properly revealed the following. It was reported that Resident 1's (R1) kitchen did not have a light. R1's room does not have a kitchen. R1's residence is 1 room with a bathroom and an outdoor patio. There is a small entrance hallway that leads into the 1 room. In the corner of the room next to the bathroom there is a small sink with an overhead cabinet and a cabinet to the left side which has a microwave oven. This area is approximately 6 feet away from R1's bed. The room is lit by a ceiling light in the entry hall by the front door and 2 lamps. Both lamps are the property of R1. Natural light comes into the room through the balcony door which has numerous windows in it. R1 reported that there should be a light above the sink provided by the facility. Staff reported that the if R1 purchased a light for above the sink they could install it for R1 but they declined. The room has 2 lamps that light the room. There is no regulation requirment for a lamp to be mounted under a cabinet. Unfounded The room has lighting and there is no kitchen as the unit is only 1 room. Based on the evidence gathered the allegation is determined to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, staff do not ensure medications are properly managed for residents in care, revealed the following. It was alleged that the facility does not properly manage residents medication including Resident 1 (R1) who allegedly ran out of their PRN medication (Acetaminophen 500 mg) on or around March 20, 2025. LPA reviewed 7 resident medications records for March and April 2025, including R1's records. LPA observed all medications are secured in the medication room in a medication cart which is kept locked. Medications only leave the medication room under staff supervision when they are being administered to residents. A review of review of records shows R1 did not receive their Acetaminophen 500 mg on March 5, 2025 and March 20, 2025. 4 out of 4 staff members interviewed reported that on those days R1 did not request the Acetaminophen 500 mg which is a PRN medication. R1 reported that they ran out of their PRN Acetaminophen 500 mg on or around March 20, 2025 and had to refill the prescription on their own. R1 did not report missing their medication any other days other than on or around March 20, 2025. 4 out of 4 staff interviewed reported that R1's PRN for Acetaminophen 500mg was recently reordered and they never ran out. A review of R1's records show that the prescription for Acetaminophen 500 mg was refilled on March 26, 2025 and the bottle was first opened on March 26, 2025. The Medication Administration Record (MAR) for R1 for March 2025 shows the only days that the PRN Acetaminophen 500 mg was not administered was March 5, 2025 and March 20, 2025. Since the prescription was filled on March 26, 2025 and there are no other discrepancies reported or noted in the records and R1 received Acetaminophen 500mg PRN each day from March 21 through March 31, R1 never ran out of medication as reported. No discrepancies were observed in 7 out of 7 resident medication records reviewed. LPA interviewed 6 residents. 6 out of 6 residents reported not having any issues with their medications. Based on the evidence gathered the allegation is determined to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided R1 reported the items are where they want. R1 has all of the required furnishings in the room, which R1 provided. The facility is not required to provide additional furniture for storage. There are no trip hazards in the room because there is a clear path to the sink, microwave oven, bathroom, bed, patio door and front door. R1 and the staff reported conflicting information. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Apr 9, 2025 · control 22-AS-20250402084342

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to follow up on a report received by the Agency. LPA met with Health Services Director and explained the reason for the visit. The Health Services Director reported they have complied with the instructions from Orange County Health Care Agency and will send a copy of the information sent to the Agency. (CCL). Health Services Director report there are no issues to report and the facility is fully staff and has an ample supply of PPE. LPA informed the Health Care Services Director to continue to report any incidents as required by regulation. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Feb 19, 2025

Type of visit: Annual/Random

On 12/7/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with David Alvarado /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (120) elderly adults ages 60 and above, of which (120) can be non-ambulatory and (4) Bed-ridden. The facility has an approved hospice waiver for (15). The facility is a two-story building with 54 resident rooms on the first floor and 43 resident rooms on the second floor. The first floor has two large living rooms, dining room, activity room and an outdoor garden courtyard with a fountain. The fountain is raised and does not present a hazard to residents. Outside of the dining room there is an outdoor promenade with tables and chairs for residents to sit outside. LPA Iniguez and the Executive Director toured the physical plant. LPA inspected a total of (6) bedrooms and (6) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 115.5°F to 116.2°F, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 10/22/24. A review of (5) residents' service files and (4) staff personnel files was done. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was given to LPA. Facility Annual Fees are not current since 11/30/24. LPA Iniguez provided current amount balance to administrator and PIN number. Per ED payment was sent to CCLD on 10/26/24. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -See D page for details. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to David Alvarado / Executive Director.the state’s words, verbatim · CDSS document, Dec 7, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Joseph Alejandre, Hanna Gough and Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPAs met with Executive Director/Administrator David Alvarado whose Administrator's Certificate expires January 6, 2026. LPAs and Executive Director toured the facility. The facility is licensed for a capacity of 120 non-ambulatory residents of which 4 can be bed-ridden and a hospice waiver for 15. The facility is a two story building with 90 resident rooms. LPAs observed the kitchen is clean and organized. LPAs observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPAs observed the refrigerators and freezer are maintained at the required temperatures. LPAs observed a 3 day emergency food and water supply stored in a storage room. LPAs and the Executive Director toured the resident rooms. LPAs observed all resident rooms inspected on the second and first floor had the required furnishings. All resident bathrooms inspected were clean and operational Hot water measured 107.9 to 113.9 degrees Fahrenheit. LPAs observed residents participating in a group activity in the piano room. The facility has 4 stairways. LPAs observed an emergency evacuation chair at each stairway. LPAs observed all fire extinguishers in the facility are fully charged. LPAs observed medication is stored in medication carts in the medication room. LPAs observed an outdoor patio with shaded seating for residents to sit outside. There is a fountain in the outdoor patio. The fountain is empty and has no water. No obstacles or hazards observed inside or outside of the facility. LPAs interviewed staff and residents. LPAs reviewed 6 resident files and medications, no discrepancies observed. LPAs reviewed staff files. No discrepancies observed, all staff files reviewed had the required training and CPR. All staff files reviewed and staff interviewed are background cleared and associated to the facility. The last fire drill was conducted on October 10, 2024. The fire sprinkler system was inspected on July 8, 2024. LPAs inspected the first aid kit. The first aid kit has all the required elements. No deficiencies observed during the visit. LPA consulted with the Executive Director concerning reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Nov 13, 2024

Allegation investigated: Facility did not issue a full refund

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by the facility's Business Office Director Peggy (...) after introducing himself, stating the purpose of the visit and listing the allegation investigated. Facility staff provided LPA with a copy from the signed Community fee receipt signed by resident R1 and the Regional Sales Specialist for Ivy Park, in addition to a final account statement dated December 19, 2023 and copies of a check from R1 signed on December 15, 2023 and a refund check by the facility Executive Director on December 22, 2023. Both the agreement and the ledger indicate that no charges were assessed to R1 and the amount on both checks are observed to match strictly. CONTINUED ON FORM LIC9099-C Unfounded CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility did not issue a full refund, the following has been concluded: On December 15, 2023, R1 signed a community fee receipt acknowledging that she was intending to move into the facility starting December 22, 2023 after issuing a payment in the amount of $3995 for the facility's community fee. As stated on the document and in accordance with Title 22 regulations, "If you decide not to move-in prior to the completion of the assessment 100% of the community fee will be refunded to you. If an assessment has been conducted, there is a $500 fee per person for the assessment an the remaining community fee will be refunded to you." When the prospective resident informed the facility of their intent to not move in, no assessment had been conducted yet. Correspondingly, the final account statement for R1 shows an initial deposit in the amount of $3995 and a determination showing the amount as refundable in full. A deposit handed to the resident on December 22, 2023 was determined to also be in that amount per a copy of the check handed to R1 in person. The lease on a unit at the facility was considered to be cancelled per the facility's ledge as of December 19, 2023. As a result, the allegation is determined to be Unfounded, meaning that meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 22-AS-20240126081206