Ivy Terrace at South Coast

Allegation investigated: Staff did not allow the resident to have visitors Staff did not allow resident to have private telephone calls Staff are overmedicating resident

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on January 29, 2026. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Anna Pastores. LPA explained the reason for the visit. This Department has investigated the complaint alleging that staff did not allow the resident to have visitors. Regarding the allegation the following was revealed: During the investigation LPA reviewed the Ivy Terrace at Santa Ana Resident sign in/sign out sheets dated August 5, 2025, through February 4, 2026. Per Resident sign in/sign out sheets, on January 23, 2026, and January 27, 2026, Resident's (1) family visited and sign out R1 for an outing. During the investigation LPA reviewed the Ivy Terrace at Santa Ana Admission Agreement dated August 15, 2025, for R1. Per Admission Agreement, under Visits and Communication it states visitors are welcome at any time provided that they respect the rights of other residents and staff and abide by visitation policy. CONTINUED ON LIC9099-C... Unsubstantiated During the interviews with residents, Resident 1 (R1) reported that her family can visit anytime. R1 stated that she has never been denied visitors. Per R2, his wife visits everyday. R3 reported that she can have visitors. During the interviews with staff, S1 reported that the residents are always allowed to have visitors. During the interviews the ED reported that there are no restrictions on visitations unless there is a restraining order. Per ED, staff are not having visitation restrictions for R1. Regarding the allegation that staff did not allow resident to have private telephone calls, the following was revealed: During the investigation LPA reviewed the Ivy Terrace at Santa Ana Admission Agreement for R1. Per Admission Agreement, under Resident's Personal Rights it states to have reasonable access to telephones, to both make and receive confidential calls. During the interviews with residents, R1 reported that she has privacy and stated that she was never told to put the telephone on speaker. Per R2, he can make private calls. During the interviews with staff, S1 reported that she has never witness residents being forced to put the telephone on speaker. During the interviews the ED reported that the residents use the front lobby telephone and stated that staff give the residents privacy when making a call. Regarding the allegation that staff are overmedicating resident, the following was revealed: During the investigation LPA reviewed the Physician Report dated July 24, 2025, for R1. Per Physician Report R1 is not able to manage and store own medications. During the course of the investigation LPA reviewed documents including the Medication Administration Record (MAR) dated January and February 2025, for R1. Per MAR, R1 is being administer her medications as prescribed. During the interviews with residents, R1 reported that she does not take medications. Per R2, staff give him his medication as needed. During the interviews with staff, S1 reported that the residents are never overmedicated. During the interviews the ED reported that R1 is not being overmedicated and stated that the medications are given as prescribed. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 22-AS-20260129091147

Type of visit: Prelicensing

On November 18, 2025, Licensing Program Analyst (LPA) Garlli Tat conducted an announced pre-licensing visit to the facility and was greeted and granted entry by applicant Judith Torres. LPA observed the Administrator's Certificate expires on July 15, 2026 and is posted at the lobby and office. The Department received an application for a Change of Ownership for the Residential Facility for the Elderly (RCFE) on October 30, 2025. LPA toured the exterior and interior portion of the facility with the applicant. Structure: Facility is a single level structure. On April 10, 2025, The Orange County Fire Authority granted fire clearance for a capacity of 72 residents (68 of which may be non-ambulatory, four may be bedridden, and hospice waiver for 15) on August 28, 2025. There are a total of 36 bedrooms. There is a current census of 46 residents. Bedrooms: All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept hazard free. Bathrooms: The bathrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in bathrooms were measured to be at 110 degrees Fahrenheit. Linens and Hygiene Supplies: Adequate supply of linens is stored in the storage room. Posters, Emergency Phone Numbers, Exit Plan: LPA observed the PUB475 "See Something, Say Something" poster posted at the front lobby and dining room. Emergency disaster plan is posted in the lobby. Continued on LIC 809-C. Food Service and Menu: 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. Facility had back-up emergency food and water supply located in the storage room. Smoke and Carbon Monoxide Detectors: Smoke and carbon monoxide alarms have been tested on April 10, 2025. Fire Extinguisher: Fire extinguishers were fully charged, and mounted in the hallways, and tagged for the date of April 10, 2025. Fire sprinklers were also tested on this date. Appliances: The kitchen is fully equipped with a stove, oven, dishwasher, refrigerator and freezer. Washer and dryer are located in the laundry room. Toxins: Toxins are locked and inaccessible to residents in a storage room. Medications, PPE First-Aid Kit and Manual: LPA observed the First Aid kit located in the medication room and had all the required components. Medications were locked in the medication room. Backyard: No bodies of water were observed. The outdoor area is free of hazards and there are seating areas under shade. The exterior doors are secured for resident safety. Resident and Staff Files: Records were kept locked in the Executive Director's office and in the medication room. Recreational Activities: The facility has a schedule of daily activities and a daily menu posted in the dining room. LPA reviewed the Component III presentation with the applicant Judith Torres. The applicant has met all pre-licensing requirements. LPA will submit notification to Centralized Applications Bureau (CAB) for final review prior to license being issued. LPA conducted an exit interview with applicant Judith Torres and a copy of this report was reviewed and provided to the facilitythe state’s words, verbatim · CDSS document, Nov 18, 2025