Ivy Park at Fullerton

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Other

On September 25, 2026, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim made an unannounced visit for the purpose of issuing an amended report page 9099-C in connection to Complaint Control No: 22-AS-20251210151854. LPA met with Administrator Christina Matsumoto and explained the reason for the visit. Amended Report Page 9099-C was explained and issued. LPA provided consult regarding the administrator's concerns. An exit interview was conducted with Administrator Christina Matsumoto, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Sep 25, 2026

Allegation investigated: Staff does not ensure transport vehicle used for residents is maintained in safe operating condition Resident sustained injury due to staff not securing them properly

On September 23, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegations listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director Christina Matsumoto was notified and later arrived to assist with the visit. During the course of the investigation, the Department inspected the facility's transportation vehicle, conducted staff interviews, a resident interview, reviewed and obtained pertinent documents for this complaint. Regarding the allegation that, staff does not ensure transport vehicle used for residents is maintained in safe operating condition, the following has been concluded: During the investigation, the Department inspected the transport vehicle that is used for residents in care. The Department observed the vehicle to be in good condition with no apparent safety concerns. The Department also tested each seat belt and strap located in the vehicle and observed them to be operational. CONTINUED ON LIC9099-C Unsubstantiated During the investigation, the Department also obtained the last three inspection reports for the facility's transportation vehicle. The inspection reports were dated April 14, July 14, and September 21, 2026. The Department observed that the inspection reports did not indicate any needed repairs or any hazards that would make the vehicle unsafe to use. Regarding the allegation that, resident sustained injury due to staff not securing them properly, the following has been concluded: During the investigation, it was revealed that on September 8, 2026, Resident #1 (R1) was being transported to a scheduled appointment by Staff #1 (S1) in one of the facility's transportation vehicles. During the transport, S1 encountered a pothole which caused the vehicle to suddenly rise and fall. R1 then complained of pain to their back. S1 then pulled the vehicle over and called Staff #2 (S2), and 9-1-1. R1 was then transported to the hospital as a result of an injury sustained. During the investigation, the Department conducted interviews with all individuals involved, including R1, S1, and S2. During the interview with R1, R1 was unable to state if they were, or were not properly secured, during the transport. During the interview with S1, S1 denied the allegation and reported that they properly secured R1 before the transport by using the appropriate belt and straps. During the interview with S2, S2 reported that they observed R1 to be properly secured when they arrived to further assess R1. The Department was unable to gather any evidence during the investigation to support the complaint allegation. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the two allegations above are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Christina Matsumoto and a copy of the report was provided at time of visit. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." During the investigation, it was revealed that on September 8, 2026, Resident #1 (R1) sustained a compression fracture to their T7 vertebral body as a result of an incident that occurred while R1 were being transported to a scheduled appointment. During the transport, the driver of the facility vehicle encountered a pot hole, and R1 complaining of back pain afterwards. R1 was subsequently transported to the hospital as a result of injury sustained, and therefore, a written report documenting this incident was required, since it impacted the health and safety of R1. The Department also reviewed R1's after visit discharge summary which confirmed that R1 sustained a compression fracture to their T7 vertebral body. During the investigation, the Department conducted interviews with R1 and staff who were witnesses to the incident that occurred on September 8, 2026. All individuals interviewed confirmed that the incident occurred and that R1 sustained an injury. The Department observed that the facility submitted an Unusual Incident/Injury Report to the Orange County Regional Office that confirmed the incident regarding R1 on September 8, 2026. The Unusual Incident/Injury Report was dated September 16, 2026, and sent to the Orange County Regional Office on the same day. Therefore, the Unusual Incident/Injury Report was not created, or submitted to the Orange County Regional Office within the seven day required time frame. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, staff does not ensure reporting requirements are followed. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D page. An exit interview was conducted with Executive Director Christina Matsumoto. A copy of the report and appeal rights were provided at time of visit.the state’s words, verbatim · CDSS document, Sep 23, 2026 · control 22-AS-20260916134233

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 30, 2026

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports.. (1) A written report shall be submitted to the licensing agency .. within seven days..(D) Any incident which threatens the welfare, safety or health of any resident.. This requirement was not evidence by: Based on interviews and records reviewed, the Licensee did not ensure that the facility submitted a written report to the Department regarding Resident #1 (R1) injury on September 8, 2026, within the required 7 day time frame. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 23, 2026

Plan of correction: The Executive Director stated that she will complete a written statement that the facility will abide by the regulation cited. The Executive Director agreed to provide LPA the written statement via email or fax by POC due date.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff are not responding to residents call buttons in a timely manner

On August 20, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegation listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director Christina Matsumoto was present and assisted on today's visit. During the visit, LPA conducted resident interviews, staff interviews, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, staff are not responding to residents call buttons in a timely manner, the following has been concluded: It was alleged that staff did not respond to Resident #1 (R1) call button in a timely manner. During the investigation, LPA conducted an interview with R1. R1 corroborated the allegation and reported that staff did not respond to him in a timely manner on July 11, 2026. R1 stated that it took staff approximately thirty minutes to assist him on that day. Additionally, during the visit, LPA tested the call button for R1. LPA observed that staff responded to the call button request in less than five minutes. LPA conducted an additional seven resident interviews. CONTINUED ON LIC9099-C Unsubstantiated Three residents reported that they have not used their call buttons before, and therefore were unable to provide any information into this allegation. However, the remaining five residents denied the allegation and reported that staff have assisted them in a timely manner after using their call buttons. LPA also conducted six staff interviews. During the staff interviews, it was discovered that the facility experienced a network outage on July 11, 2026, which affected their call button system. It was reported that staff had to conduct manual room check-ins while the network system was restored but that there was sufficient staff available during this time. LPA also discovered that the facility's call button system does not keep a record of the call button activations and the time it takes for staff to respond to the request. However, one staff interviewed corroborated the allegation and reported that there have been times were staff have been unable to respond timely to a call button due to a staffing shortage on that shift. However, five out of the six staff interviewed denied the allegation and reported that staff are able to respond timely to call button request. The five staff also reported that they have not received any complaints from residents regarding their call buttons. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the one allegation above is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Christina Matsumoto and a copy of the report was provided at time of visit.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 22-AS-20260811101810

Type of visit: Case Management - Incident

On June 22, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to follow up on a self reported death report that was received by the Orange County Regional Office on June 15, 2026, for Resident #1 (R1). LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Christina Matsumoto was present and assisted on today's visit. On today's visit, there were seventy four residents in care. During the course of the visit, LPA conducted a file review for R1. LPA reviewed and obtained documents for R1 including Physician's Reports, Resident Assessments, Individual Service Plan, and Medication orders. LPA also conducted one staff interview. Based on records reviewed and information gathered during the visit, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Executive Director Christina Matsumoto and a copy of the report was provided at time of visit.the state’s words, verbatim · CDSS document, Jun 22, 2026

Type of visit: Case Management - Deficiencies

On December 11, 2025, Licensing Program Analyst (LPA) Edward Kim conducted a case management deficiency visit unrelated to an allegation of complaint # 22-AS-20251210151854. LPA Kim conducted a health and safety check. LPA observed on the facility records the annual licensing fee was not paid as of December 11, 2025. The annual licensing fee was due on November 26, 2025. A deficiency was cited during the visit per Title 22 Division 6 Chapter 8 of the California Code of Regulations. The annual licensing fee was due on November 26, 2025, and was not paid as of December 11, 2025. An exit interview was conducted, and a copy of this report and appeal rights were provided to Interim Executive Director Samuel De Guzman.the state’s words, verbatim · CDSS document, Dec 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87156(a) · Plan of correction due date: Dec 26, 2025

87156(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement is not met as evidenced by: Based on observation, interviews, and record review, the licensee did not comply with the section cited above. As of 12/11/2025, LPA Kim observed the licensing fees due on 11/26/2025, were not paid. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: Licensee states they will pay the annual licensing fees and send proof to CCLD via email to edward.kim@dss.ca.gov by POC due date December 26, 2025.

Type of visit: Required - 1 Year

On November 4, 2025, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and met with Interim Executive Director (ED) Sam de Guzman. The facility is licensed to operate for eighty-five (85) nonambulatory residents of which eight (8) may be bedridden and have a hospice waiver for twenty (20) residents. The facility is a two-story structure and consists of the following: sixty-three (63) resident bedrooms, six (6) offices, sixty-eight (68) bathrooms, living area, two dining areas, beauty salon, TV room, kitchen, bistro, two activity rooms, theater room, lounge, parking garage, and outdoor seating area. LPA Kim toured inside and outside of the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 112, Resident Room 125, Resident Room 153, Resident Room 201, Resident Room 216, Resident Room 229, Resident Room 231, Resident Room 240, and Resident Room 255. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 115.3 degrees F to 117.5 degrees F. A comfortable temperature of 73 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the parking garage. The facility has fourteen (14) fire extinguishers that were charged, mounted throughout the facility, and serviced on October 29, 2025. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were inspected by CAL Building systems on December 6, 2024. Sprinkler system was inspected and tested by Cal Building Systems on December 6, 2024. A working telephone (714-738-3656) and internet capable devices for teleconferencing purposes remain available. Emergency drill logs were last conducted on October 23, 2025, and are conducted monthly. LPA observed the facility had current Evidence of Liability Insurance effective May 1, 2025, to May 1, 2026. LPA Kim conducted an audit of eight (8) resident files (R1-R8), six (6) staff files (S1-S6), and medication and medication administration record. LPA observed R1’s diagnosed with dementia with a physician’s report dated October 11, 2024, and R2’s diagnosed with dementia with a physician’s report dated November 2, 2024. LPA Kim conducted interviews with six (6) staff and five (5) residents. A Technical Violation was assessed during the visit in regard to R1 being diagnosed with dementia with a medical assessment dated October 11, 2024, and R2 being diagnosed with dementia with a medical assessment dated November 2, 2024. An exit interview was conducted, LIC811, LIC9102, and a copy of this report was provided to Interim Executive Director Sam De Guzman.the state’s words, verbatim · CDSS document, Nov 4, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure resident's hygiene needs were met Staff did not ensure facility was cleaned properly Staff did not ensure resident's bathroom had toilet paper

On April 17, 2025, at 8:00 AM Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit at the above facility for the above allegations. LPA Kim met with Director Kathleen Olson and LPA explained the purpose of the visit. During today's visit, LPA Kim conducted a Health and Safety check, and no concerns were observed. LPA Kim reviewed and obtained copies of one (1) resident record, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans, and other pertinent records. LPA obtained residents roster, staff roster, and staff schedule. LPA Kim conducted one (1) resident interviews, two (2) witness interviews, and six (6) staff interviews. The investigation revealed the following: CONTINUED ON LIC9099-C Unsubstantiated Staff did not ensure resident’s hygiene needs were met It is alleged that resident diagnosed with dementia has long nails, unwashed (greasy) and unbrushed hair due to lack of care. Reporting Party reported noticing resident was using another resident’s shampoo products. Based on record review, physician’s report dated October 17, 2024, shows the resident has dementia; has the capability for self-care by being able to bath self, able to dress/groom self, and able to care for own toileting needs. Per Pre-appraisal dated October 18, 2024, resident only needs prompting with bathing, hair care, personal hygiene. A shower log indicates R1 refused to take a shower on February 28, 2025. Based on interviews conducted, six out of six staff denied that staff did not ensure resident’s hygiene needs were met. Two out of two witnesses claimed staff did not ensure resident’s hygiene needs were met. R1 stated that the facility met the resident’s needs and likes the staff. Staff would constantly ask multiple times per day to prompt resident to shower and/or brush their hair, resident would sometimes refuse. Based on observation, during the visit LPA observed in the morning that R1 was with fifteen other residents in the activity room in the Memory Care wing are clean and well groomed. LPA observed the R1 having hair that was clean and brushed, and their nails were of normal length. LPA observed none of the shower products in R1’s bathroom had a different name on them. One shampoo was labeled with R1’s name and one lotion was labeled “A5.” Based on evidence gathered, there is no sufficient evidence gathered to corroborate the above allegation. Staff did not ensure the facility was cleaned properly It is alleged the facility was dirty. Based on interviews conducted, six out of six staff denied the staff did not ensure the facility was cleaned properly. Two out two witnesses claimed the staff did not ensure the facility was cleaned properly. Witness #2 (W2) stated the resident’s bathroom was dirty with grime in the toilet and the sink. Interview with R1 confirms the facility including their bedroom clean and is satisfied with the condition of the bedroom. CONTINUED ON LIC9099-C Based on record review, the cleaning schedule indicates each bedroom is cleaned once a week by the maintenance staff. Common areas are cleaned every day. Based on observation, LPA observed the resident’s bedroom to be clean, sanitary, and in good repair. There was no smell, the sink and toilet were clean and operational, and the carpet was vacuumed. LPA observed housekeepers cleaning in common areas throughout the day, and cleaning assigned rooms according to schedule. Based on evidence gathered, there is no sufficient evidence gathered to corroborate the above allegation. Staff did not ensure resident’s bathroom had toilet paper. It is alleged by the Reporting Party there was no toilet paper in resident’s bathroom. Based on interviews conducted, six out of six staff denied staff did not ensure R1’s bathroom had toilet paper. One staff states in a bedroom there would be two rolls of toilet paper in the bathroom. Two out of two witnesses claimed the staff did not ensure R1’s bathroom had toilet paper. Interview with R1 confirmed they have enough toilet paper every day. Based on observation, LPA Kim saw two rolls of toilet paper in the bathroom in R1’s bedroom. One was in the toilet paper holder in the bathroom and one on top of the toilet in reach of the R1. Based on evidence gathered, there is no sufficient evidence gathered to corroborate the above allegation. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted a copy of the report was provided to Director Kathleen Olson.the state’s words, verbatim · CDSS document, Apr 17, 2025 · control 22-AS-20250409155948

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with Business Office Director (BOD) Cherie Harris. Administrator (AD) Christina Hale arrived shortly after. An application for Change of Ownership (CHOW) to operate a Residential Care Facility for the Elderly (RCFE) was submitted to Community Care Licensing (CCL) on November 13, 2023. The facility is to have a capacity of 85, of which 77 can be nonambulatory and eight bedridden. Facility phone number 714-738-3656. LPA observed the following. Structure: The facility is a two-story structure and consists of the following: 65 resident bedrooms, six offices, living room area, dining room, private dining room, two activity studios, salon, theater room, kitchen, bistro, lounge parking garage, and outdoor seating area. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is an enclosed courtyard and a sensory room in the memory care unit. LPA did not observe any obstacles or hazards in the courtyard and/or hallways. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. Signal system Signal system was tested and observed to be operable. CONTINUED ON LIC9099-C... Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the various storage rooms. Medications, First-Aid Kit & Book: Medication is stored in a locked staff office in a locked medicine cart. First aid kit is stored in the medication room. The first aid kit has all the required elements. Resident & Staff Files: Records will be kept locked in a staff office. Pool/Jacuzzi: No bodies of water were observed. Fire Extinguisher: A fire extinguisher is located in every hallway and in the kitchen of the facility. Fire extinguishers were fully charged with service tags dated October 17, 2024. Reading Material, Games, Equipment & Materials: The facility has reading books, arts and crafts supplies, board games, puzzles, and other recreational materials for resident use stored in the activity room. Bedrooms Staff: There is no staff bedroom. Bathrooms: All bathrooms have working plumbing. Hot water measured between 107.6 and 112.2 degrees Fahrenheit. Linens & Hygiene Supplies: A supply of extra linen was stored in the laundry rooms. Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review, an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was also posted and available. Food Service: A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand. Smoke Detectors: Carbon monoxide detectors tested operational. Fire alarm was tested on April 30, 2024 by Johnson Controls. Appliances: Gas burner stove, refrigerators, walk-in freezer, microwave, washers, and dryers were inspected and observed to be operational. Fire clearance: Fire Clearance approved by a fire inspector of Fullerton Fire Department on May 16, 2024. Special conditions noted, "No restraints. No smoking in rooms utilizing air induced mattresses. Temporally bedridden provide the Fullerton Fire Department with notification within 48 hours of resident's admission or retention in the facility." Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. LPA advised Applicant to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for inquiries and to submit incident reports. The applicant has met all pre-licensing requirements. LPA will submit notification to CAB (Centralized Application Bureau) in Sacramento for final review prior to license being issued. Applicant was informed today that the final approval will be processed by CAB in Sacramento. Exit interview was conducted and a copy of this report was left with the applicant.the state’s words, verbatim · CDSS document, Nov 7, 2024