Ivy Park At Otay Ranch

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.

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: Neglect to resident resulting in serious bodily injury. Staff did not ensure resident's needs were met

On 11/7/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Executive Director, Diana Weinstein and explained the purpose of the call. Regarding the allegation of neglect to resident resulting in serious bodily injury, resident (R1) was sent to the hospital and had undergone surgery. According to records, on 7/15/2024, during medication pass, R1 reported experiencing pain. R1 was asked if he/she had a fall but kept denying. PRN medication was given but was ineffective. Staff asked family to send R1 to hospital for further evaluation. On the same day, R1 was sent to hospital and was evaluated. For the allegation of staff did not ensure resident's needs were met, based on the records reviewed, there is constant alert charting for R1. There are also notes from facility staff about R1s behaviors and daily activities. Based on records review, the department has determined that although the allegations may have happened or are valid, tthe state’s words, verbatim · CDSS document, Nov 7, 2025 · control 08-AS-20240805130104

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: Staff did not prevent resident from eloping from facility

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit and also delivered findings regarding the above complaint allegation. LPA introduced himself and disclosed the purpose of the visit with Memory Care Director Trobell Orana. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observations, records review, interviews with staff and resident. It was alleged that facility staff did not prevent Resident 1 (R1) from eloping from the facility. It was reported that R1 eloped from the facility and was not located for several hours. R1's Physician's Report dated August 13, 2025 revealed R1 has a diagnosis of Major neurocognitive disorder. R1 is not able to leave the facility unsupervised and R1 becomes disoriented at times. Substantiatedthe state’s words, verbatim · CDSS document, Sep 11, 2025 · control 08-AS-20250904161054

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: Resident sustained an injury due to lack of supervision

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced visit at the facility to open a complaint investigation regarding the above mentioned allegation. LPA identified themselves, stated the purpose of the visit and was greeted by Executive Director (ED) Calais Anguiano. It was alleged that Resident 1 (R1) sustained an injury due to lack of supervision. It was reported that R1 fell down on two consecutive days, October 21st and October 22nd. On the second incident, R1 sustained a head injury and was sent to the hospital. It was further reported that Staff 1 (S1) was the responsible caregiver during both incidents. LPA reviewed facility resident rosters dated September 2024 through February 2025. LPA also reviewed facility staff rosters dated September 2024 through February 2025. Review of records revealed R1 did not reside at the facility and S1 did not work at the above mentioned facility. LPA interviewed Outside Source (OS) who stated that R1 and S1 were located at athe state’s words, verbatim · CDSS document, Feb 20, 2025 · control 08-AS-20250212120748

Allegation investigated: Facility financially abused resident Staff moved a resident who doesn’t have dementia to the memory care unit Staff instructed residents not to use their pendants, or they will be charged extra for using them

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Maintenance Director Justin Brown and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA observation, records review and interviews with facility staff, residents and outside sources. It was alleged that facility staff financially abused Resident 1 (R1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) It was reported that R1 was paying for three apartments without R1's knowledge. LPA reviewed the standard fee schedule dated January 2024 as well as billing invoices dated June 2024 through August 2024. The billing invoices did not show that R1 was charged for three apartments. A slight price increase occurred on the July invoice when R1 moved to the memory care unit.the state’s words, verbatim · CDSS document, Sep 25, 2024 · control 08-AS-20240729110908

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: Staff neglected resident resulting in hospitalization.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Calais Anguiano and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA direct observation, records review and interviews with facility staff. It was alleged that staff neglected Resident 1 (R1) resulting in hospitalization.[an LIC 811 Confidential Names List was provided to the facility representative to identify the resident.]It was reported that R1 fell in their room and called for staff assistance multiple times. An outside party called emergency services for R1 and R1 was transported to the hospital. Interviews were conducted with seven staff members, during this time period. Of the seven staff members, all reported that staffing was an issue and five of the seven reported that either residents did nthe state’s words, verbatim · CDSS document, Jul 29, 2024 · control 08-AS-20211115095357

Allegation investigated: Neglect/lack of supervision resulted in resident sustaining head injury. Licensee did not address resident's change in condition.

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced a follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Business Office Director Silvia Garcia. Throughout the investigation, the Department secured records and conducted interviews with external and internal sources. It was alleged neglect/lack of supervision resulted in a resident sustaining a head injury. On 05/18/2023, the Department received an SOC 341, a report of Suspected Dependent Adult/ Elder Abuse. It was reported Resident # 1 (R1) had sustained an unwitnessed fall on 5/3/23 and was transported to the hospital for further evaluation. On 5/4/23, 911 was again called to the facility as R1 had sustained another fall resulting in head trauma. (See LIC 9099C form for continuation of report.) Unsubstantiatedthe state’s words, verbatim · CDSS document, May 21, 2024 · control 08-AS-20230518133003

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: Resident sustained injuries due to lack of care from staff

Licensing Program Analyst (LPA) Ramon Serrano, conducted an unannounced Complaint Visit. LPA introduced himself and discussed the purpose of the visit with Executive Director Calais Anguiano. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of records review and interviews with facility staff and outside source. It was reported to CCL that Resident 1 (R1)(an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) had an unwitnessed fall and sustained bruising. It was alleged that R1 sustained those injuries due to lack of care from staff. Records review revealed R1 had an unwitnessed fall on February 4, 2024. Hospital discharge records revealed no new findings or new medications. Facility staff notated on February 5, 2024 at approximately 2pm; R1 was confused and crying and a "PRN" was given to R1. R1 refused to eat dinner that same day and was "very confused." Facility staff notified R1's POthe state’s words, verbatim · CDSS document, Feb 12, 2024 · control 08-AS-20240207120418

Allegation investigated: Staffing is not sufficient to meet resident's needs.

Licensing Program Analyst Becky Kennedy concluded the investigatioSilvia Garcia, Business office Manager. LPA advised her of the reason for today's visit and delivered the investigation findings on the above allegation. The investigation into the above allegations consisted of interviews with internal sources, a review of internal and external documents, and a tour of the facility. It was alleged that the facility’s staffing is not sufficient to meet resident's needs. The investigation revealed that when a resident pushed their call alert button often a staff member responded in less than five minutes, however it was not uncommon for call alerts to be answered in more than 20 minutes, 30 minutes, to over an hour. Substantiatedthe state’s words, verbatim · CDSS document, Feb 2, 2024 · control 08-AS-20211011082146

Allegation investigated: Facility staff were not adequately trained. Facility staff mismanaged the residents' medications.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Calais Anguiano and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA direct observation, records review and interviews with facility staff. It was alleged that facility staff mismanaged resident medications and were not adequately trained. It was reported to CCL that med-techs lack proper medication administration training. It was also reported that facility staff are not properly documenting when the residents medications are unavailable. LPA reviewed the training file of three random facility staff members. Staff 1's (S1) training file was reviewed. S1 shadowed another facility staff and completed the following tasks from 11/5/23-11/9/23; 3 hours of "QMAR" videos, using a bubble pack card, readingthe state’s words, verbatim · CDSS document, Jan 23, 2024 · control 08-AS-20240122104916

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: Staff did not provide 60-day notice prior to rent increase.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Calais Angiano and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of records review and interviews with facility staff. It was reported to CCL that staff did not provide resident with a 60-day notice, prior to rent increase. It was alleged that Resident 1 (R1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the clients) received a rent increase for the months of July and August 2023 without a 60-day prior notice. Records review revealed R1's POA signed an admission agreement on September 14, 2020. The admission agreement indicated the facility would give a 60 days' prior written notice to the resident/POA regarding any change in the monthly fees. Substantiatedthe state’s words, verbatim · CDSS document, Aug 29, 2023 · control 08-AS-20230802150635

Allegation investigated: Staff did not meet resident's hygiene needs Staff did not provide incontinence care

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced complaint investigation visit to follow up on the investigation of the above allegations. LPA met with the Executive Director, Calais Angiano to whom she discussed the purpose of the visit. During this visit, LPA conducted a tour of the memory care unit. In addition, LPA conducted additional interviews and reviewed resident and facility records. LPA concluded the investigation and delivered the findings. The Department investigated the above-listed complaint allegations. The investigation consisted of observations, a review of relevant records, and interviews with facility staff and outside sources. On January 25, 2022, Community Care Licensing (CCL) received a complaint alleging that facility staff did not meet a resident’s hygiene needs (R1), [an LIC 811 Confidential Names List was provided to staff to identify the resident]. (Continue at LIC 9099C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 28, 2023 · control 08-AS-20220125092004

Allegation investigated: Staff spoke inappropriately to residents Staff did not attend to residents’ call buttons in a timely manner

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA met with Executive Director, Calais Angiano, and shared findings. The Department investigated the above-listed complaint allegations. The investigation consisted of an inspection of the facility, observations, multiple interviews with residents, and staff, and a detailed review of relevant records. On July 27, 2023, Community Care Licensing (CCL) received a complaint alleging that staff spoke inappropriately to residents. Specific details of when this occurred were not obtained. However, during the investigation, facility management indicated that on July 26, 2023, a staff member reported an incident they witnessed when a care staff member made inappropriate comments to a resident. A second incident was also reported on August 8, 2023, of unprofessional misconduct between two care staff members in the presence of an outside source. (continue at LIC9099C) Substanthe state’s words, verbatim · CDSS document, Aug 28, 2023 · control 08-AS-20230727122042