Ivy Park at Fullerton

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