Ivy Park of Wellington

Allegation investigated: Staff left resident unattended on toilet with no clothes on for an extended amount of time.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation to the above identified complaint allegation. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Brenda Myers, Interim Executive Director and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, resident file review and interviews conducted. It is alleged that staff left resident unattended on the toilet with no clothes on for an extended amount of time. The interview with staff stated that on August 27, 2025, resident (R1) was being assisted with toileting needs, physical therapist arrived to R1’s apartment and did not knock and proceeded to walk in. Continued on LIC9099-C Unsubstantiated R1 was undressed when physical therapist walked in and staff covered R1 with body and asked for them to wait. Staff stated that R1 was not left unattended. The interview with R1 stated that staff assist them with their needs, but there was an incident that happened where they were assisted with changing clothes and toileting needs when therapist walked in without knocking and was uncomfortable. Staff told therapists to please wait while they finished assisting me. Resident stated that they were not left unattended and staff finished helping them get dressed so they can do therapy. Based on the information mentioned above, the Department is unable to ascertain if the allegation 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 violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Sep 22, 2025 · control 22-AS-20250828135635

Allegation investigated: Staff do not respond to resident's calls for assistance in a timely manner.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation to the above identified complaint allegation. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Brenda Myers, Interim Executive Director and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, resident file review and interviews conducted. It is alleged that staff do not respond to residents’ calls for assistance in a timely manner. An interview with staff stated that when a pendant is pressed that common practice on response time is 15 minutes max and staff respond on a timely manner. LPA conducted a facility visit on September 3, 2025, and Continued on LIC9099-C Substantiated toured the resident’s (R1) apartment, upon entry LPA found R1 upset and crying in their bedroom due to pressing pendant for assistance and have not been checked on. LPA walked to the front desk of the facility and arrived at 11:00am. LPA observed on the receptionist computer that the call logs reflected R1’s pendant had been pressed at 10:29AM and had not been checked on. Record review for pendant call log reflected that for September 3, 2025, pendant call that time was pressed at 10:29am response time was 40 minutes and 40 seconds. Review of records from August 3, 2025, to September 11, 2025, pendant response time was anywhere from 1 minute 30 seconds to 95 minutes 39 seconds. During the course of the investigation, there was sufficient evidence to substantiate the allegation. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. See LIC9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility representative and a copy of this LIC9099 and LIC9099-D, along with a copy of the appeal rights was left at the facility. and observed housekeeping staff cleaning resident apartments on various floors. An interview with staff stated that residents’ apartments are cleaned once a week and are on a weekly schedule. Records revealed that the facility has housekeeping schedules where residents’ apartments are listed on different dates and various of shifts. Resident interview revealed that their apartments do get cleaned as schedule, see staff clean blinds and clean that apartment thoroughly. They don’t always pick up every trinket and dust them, but apartments are cleaned and sanitized as they should once a week. It is alleged that staff are unable to communicate with residents due to a language barrier. Interview with 7 of 7 residents stated that they are able to communicate with staff and never have had an issue with staff not being able to understand their needs. Residents stated that even though they do not speak perfect English communication is not an issue. Interview with staff stated they have never gotten any complaints that resident have had any communication difficulty with the care staff. It is alleged that staff do not provide adequate laundry service. Interview with staff stated that laundry service for residents is scheduled once a week and residents are sent on a scheduled basis that reflect weekly. Per admissions agreement laundry service is on a weekly basis and if resident require further services it is reflected on appendix A. Per agreement facility provides basic laundry services of washing and folding clothes. Interview with 7 of 7 residents stated that their laundry is done once a week and they have never had issues with their laundry not being done. Residents stated that staff take their laundry and bring it back clean, at times care staff put away/hang their clothes and at times they forget to hang clothes. Record review revealed admissions agreement: page 2 section 2 Laundry: personal laundry assistance from the community's staff will be available. The community will provide laundry services for bed and bath linens and personal laundry on a weekly basis. Additional laundry services as needed or requested will be provided for an additional charge as set forth in Appendix A. Based on the information mentioned above, the Department is unable to ascertain if the allegation 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 violation occurred; therefore, this allegations are deemed Unsubstantiated. An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Sep 22, 2025 · control 22-AS-20250902110950

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 29, 2025

Basic services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on record review and facility tour conducted by LPA, there were multiple instances of excessive response times that were recorded. This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Sep 22, 2025

Plan of correction: Executive Director will assign the Health Services Director to keep track and audit pendant pushes regularly and keep documentation, conduct in-service training and identify root causes of excessive wait times. Written documentation of the corrections to be provided to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Brenda Myers, Interim Executive Director, and LPA explained the nature of the visit. Facility is licensed for 92 ambulatory, 120 non-ambulatory residents, of which 8 may be bedridden. Facility has an approved hospice waiver for 25 residents. Delayed egress doors for memory care only. There are 10 residents on hospice during today's visit. This facility consists of two main areas. The assisted living and the memory care unit which are protected by delayed egress exits. LPA Martinez along with the Interim Executive Director toured the physical plant of both the assisted living and the memory care unit. LPA observed a bistro adjacent to the main dining room where residents can obtain different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus and the food offered is varied and healthful. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen. During the tour LPA observed residents involved in an activity as well as a posted activity schedule including games, exercise, and outings at the facility. LPA inspected that medication is centrally stored in a safe locked location; facility has 2 medication rooms on the memory care unit and on the 2nd floor. LPA inspected both locations and LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care. Resident bedrooms had the required Continued on LC809-C furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Several resident bathrooms on each floor were tested for water temperature and water temperature measured between 110.6 and 116.7 degrees F in tested bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA pushed the restroom call button in various resident rooms and response times were under five minutes. LPA observed several residents who appeared clean, and happy. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in a locked in housekeeping closet. LPA toured the memory care unit and observed a kitchen/ dining room as well as posted activity schedule for memory care residents. LPA observed residents in the memory care unit with care staff present. LPA tested the delayed egress exits/pull cord and response times were immediate. Carbon monoxide detectors tested and noted to be operational. Fire extinguishers are fully charged and had a service date of December 13, 2024. LPA observed several fire extinguishers mounted on the wall throughout the facility. Smoke detectors and sprinkler system are tested yearly by an outside agency, and LPA was provided with testing documentation, last testing was done April 22-23, 2025. Emergency drills are being conducted monthly on every shift with the last drill conducted on September 4, 2025. LPA observed stairwells have an emergency evacuation chair. Outside grounds have ample shaded seating for residents. LPA observed several courtyards with shaded seating areas for residents’ enjoyment. LPA observed a swimming pool which is under construction at the time of visit. LPA reviewed ten resident files and five staff files. All resident files contained required documentation including updated physician reports and care plans. Staff files contained required documentation including health screens, first aid, and fingerprint clearance. As a reminder LPA provided annual fee due information. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 22, 2025

Allegation investigated: Licensee is violating the fire clearance.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility by the receptionist. LPA met with Executive Director/Administrator David Armour. LPA explained the reason for the visit. Findings are based upon this investigation which included facility file review, tour of the physical plant of the facility and interviews conducted. It is alleged the license is violating the fire clearance, more specifically to non-ambulatory resident living and/or moving into the third and fourth floor of the facility. LPA obtained copies of the LIC850 Fire Safety Continued on LIC9099-C Unfounded Inspection approved July 3, 2023, by Orange County Fire Authority approved/granted for 92 ambulatory, 120 nonambulatory and 8 bedridden residents. The Special conditions notated are as follows, bedridden approved for the following rooms: B107, B109, B111, B112, B113, D201, D202, and D203. Delayed egress doors for memory care ward only. Interview with facility Administrator stated that the facility has ambulatory and non-ambulatory residents on all floors of the facility considering that fire clearance has no restrictions on any floors. The only restrictions that the fire clearance has are the specific room for bedridden residents, to which the facility currently has no bedridden residents. We have found the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at the facility.the state’s words, verbatim · CDSS document, Jul 14, 2025 · control 22-AS-20250708122727

Allegation investigated: Facility is not following their Infection Control Plan Facility did not provide the necessary cleaning services Facility did not provide adequate medical care

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to follow-up on the investigation of the three allegations listed above. LPA was greeted and granted entry by front desk staff after stating the purpose of the visit. Administrator David Armour was notified and assisted with the visit in person. The initial complaint investigation visit was conducted by licensing staff on January 8, 2025. During the visit, LPAs accompanied by facility staff toured the premises. Records maintained at the facility for six residents were requested and obtained. Three staff interviews were conducted along with one resident interview. The facility's Infection Control Plan was also requested and reviewed. A follow-up visit took place on March 17, 2025. LPA conducted six additional staff interviews and toured the facility's memory care unit accompanied by facility staff. Additional witness interviews with Orange County Public Health staff were conducted via telephone and email during the investigation. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 During the present follow-up visit, LPA requested and obtained the facility's current resident census and requested records for six current memory care residents including their identification form, individual needs and services plan as well as charting notes. LPA reviewed the documentation added to the investigation file during the visit. Regarding the allegation that Facility is not following their Infection Control Plan, the following has been concluded: LPA was able to review the Infection Control Plan and related procedures in place during the initial complaint investigation visit. Staff interviews additionally detailed the specific measures utilized during a recent outbreak of upper respiratory infections that occurred in the facility's memory care in December 2024. Measures were listed as provision of Personal Protective Equipment for staff and residents, temporary isolation with meals provided in unit and regular checks by staff, surface cleaning in addition to weekly deep cleaning of bedrooms, emphasis on hand hygiene. Witness interviews with Orange County Public Health staff evidenced that the outbreak had been adequately reported on December 26, 2024. No concerns regarding the preventative measures implemented were stated during these interviews. Multiple staff interviews also indicated that appropriate antiviral treatment had been provided. Regarding the allegation that Facility did not provide the necessary cleaning services, the following has been concluded: Reported concerns appeared to indicate insufficient frequency of cleanings due to staff disruption during an outbreak occurring in December 2024. None of the staff members interviewed during the course of the investigation made statements corroborating that the facility was temporarily short-staffed. Multiple interviewees described a complimentary organization from caregiving and housekeeping staff in order to address both the recurring scheduled cleaning and spot clean-ups. Each visit conducted included a tour of the physical plant during which no evidence of insufficient cleaning was observed by licensing staff. Records reviewed however demonstrated that staff failed to document whether cleaning services had been provided for the second half of December 2024. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Regarding the allegation that Facility did not provide adequate medical care, a review of resident records as well as facility self-reporting documents demonstrated that resident R1 was hospitalized on December 24, 2024 and diagnosed with Influeza A after which a course of antiviral medication was provided. No failure to provide medical care as needed during the period leading up to the present investigation could be found. Earlier health concerns were addressed appropriately as demonstrated by earlier discharge documents dated May 2024. Additional records reviewed including charting notes for a random selection of six residents showed adequate flagging of health needs and appropriate responses being provided in a timely manner. As a result, the three allegations listed above are found to be Unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Apr 28, 2025 · control 22-AS-20241230100233

Allegation investigated: Staff discarded residents’ meals Staff is giving medication to residents without a prescription order

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegations and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Administrator (AD) David Armour. LPA explained the reason for the visit. This agency has investigated the complaint alleging that staff discarded residents' meals. Regarding the allegation, the following was revealed: During the course of the interviews one of eight individuals interviewed confirm the allegations. During the course of the interviews with residents, Resident 1 (R1) reported that staff have never discarded their food. Per R1 she can get seconds and/or can substitute an item. During the course of the interviews with staff, Staff 1 (S1) reported that staff will only discard the food that is left over and once the residents have done eating. Per S1 if the residents do not like the food they have other options to choose from. CONTINUED ON LIC9099-C... Unfounded Regarding the allegation that staff is giving medication to residents without a prescription order, the following was revealed: During the course of the interviews with staff, S1 reported that the residents that take Ativan all have a prescription order. Per S1 she has never noticed medication missing and/or any discrepancies. S1 reported that she has never worked with S2 or S3. During the initial visit on April 02, 2025, LPA reviewed random Medication Administration Records (MARs). Per MARs, the residents that take Ativan have a prescription order. Therefore, the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or are without a reasonable basis. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA Ramirez conducted an exit interview with AD Armour, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 2, 2025 · control 22-AS-20250327143704

Type of visit: Case Management - Incident

This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on an incident reported to CCLD on February 05, 2025. LPA met with David Armour, Administrator/Executive Director and explained the purpose of today’s visit. Incidents was self reported on February 4, 2025 via incident report telephone call and LIC624 was received on February 05, 2025 regarding residents (R1) incidents of February 04, 2025. During today’s visit, LPA interviewed staff and obtained copies of pertinent documents. On February 04, 2025, at approximately 3:15am R1 left the premises via kitchen loading dock and headed towards the street. A civilian saw R1 and called 911 to report and paramedics were sent out. R1 was take to hospital for evaluation and has not returned to the community. Facility received a call from the hospital about 4:15AM informing them that R1 was at the hospital. R1 was discharged to a skilled nursing and facility staff is to re-assessed R1 prior to returning to the community. Once facility received call from the hospital informing them that R1 was there, facility staff called responsible party, Executive Director and LPA Martinez to informed them on the incident. This visit is being conducted for the purpose to review incident details and collect facility records. Facility has been in contact with hospital, skilled nursing and R1's DPOA for updated information. LPA did not observe any immediate and/or safety risks in or out of the facility. Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Executive Director and a copy of the report was provided and left at the facility.the state’s words, verbatim · CDSS document, Feb 19, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Joseph Alejandre, Brandon Lopez, and Nancy Guillen made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs met with Executive Director David Armour and explained the reason for the visit. The facility is licensed for a capacity of 220 of which 120 can be non-ambulatory, approved for 8 bedridden and a hospice waiver for 25. Facility is one building with 4 stories. The building has a central courtyard with a pool which is fenced. LPAs and the Executive Director toured the facility. LPAs observed the fireplace in the lobby is screened. The See Something, Say Something Poster is posted in the mail room and is not in the main entry way of the facility. LPAs toured the kitchen and dining room. LPAs observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPAs observed the kitchen is clean and organized. LPAs observed the refrigerators and freezers are kept at the required temperatures. LPAs toured 11 resident rooms. LPAs toured rooms on each level. LPAs observed each stairwell has an emergency evacuation chair. LPAs observed all rooms had the required furnishings. LPAs observed in the rooms inspected that all the bathrooms are clean and operational. Hot water measures between 110.0 to 116.6 degrees Fahrenheit. Medications are kept locked in the med room in a locked medication cart. The memory care unit has their own med room and medication cart which is kept locked. LPAs and the Executive Director toured the memory care unit which is on the first level. The memory care unit uses a secured perimeter and has delayed egress exits. LPAs tested 4 delayed egress exits and all exits operated properly. No obstacles or hazards observed in the memory care unit. The facility has activity rooms and sitting areas on each floor. There is an outdoor patio on the first level which has a pool. The pool fence is 5 feet tall and kept locked and is inaccessible to residents. LPAs observed the facility has emergency food and water stored in a storage room. No obstacles or hazards observed in the patio. There is shaded seating in the patio. No obstacles or hazards observed in the facility. LPAs reviewed resident medications and files. LPAs reviewed 11 resident files, no discrepancies observed. LPAs reviewed 10 staff files, no discrepancies observed. Staff had the required training and is associated to the facility. The last emergency drill took place on October 17, 2024. The fire suppression was tested on April 26, 2024. The facility is operating within their license. 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, Oct 21, 2024

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility to conduct and unannounced Case Management Incident Follow Up. LPA entered the facility and was greeted by Robin Colton in Reception. LPA stated the purpose of the inspection. Colton brought LPA to Interim Executive Director (IED) Kathleen Olson's office. LPA stated they are following up on the Unusual Incident Reports submitted to CCL on 1/24/24 regarding both spouses in a married couple. LPA obtained copies of the Admission Agreements, Resident Information Form and Resident Ledger pertaining to the couple. IED also provided LPA with a written list indicating each day the couple visited the facility for a meal. IED pulled these dates from Dining Room Meal Logs. LPA also obtained from the facility staff the Case Number, Detective name and Police station associated with the incident. Additionally, LPA obtained a photo of the Coroner's Seal affixed to the couple's private residence. Based on Record Review LPA determined the couple had been paying to rent a room at the facility since August 31, 2023. Based on interview with the IED, the residents paid to rent the room, visited the facility but resided at a private residence away from the facility. LPA conducted a health and safety check and noted two panels missing from the ceiling tiles. IED stated the removed tiles sustained water damage during recent rain and were removed so they could dry. IED stated service has been scheduled to repair ceiling tiles. IED stated that when the couple moved in, they only moved in a few pieces of furniture and stated they would not be residing in the room and did not want to receive service. LPA toured the couple's room and noted a bed in each room, two wooden chairs in the living room and a wooden table in the living room. LPA observed no personal items, food or entertainment devices in the facility apartment. LPA obtained photos of the room. (Continued on LIC809C) Based on Record review, the couple came to the facility 21 times for meals in September, 14 times for meals in October, 5 times in November and 1 day in December. The couple was last at the facility on December 4, 2023 for a meal. On December 18, 2023 Jessica Bacca, Senior Sales Manager, began calling the couple to find out their whereabouts. After being unable to get a hold of the couple via phone, the facility began calling the emergency contact listed on the Resident Information Form for the couple. The facility was unable to get a hold of the emergency contact. Iberia Tarin, Business Office Director called the couple on January 3, 2024 following a declined payment. LPA verified via Record Review the facility froze the couple's account on January 4, 2024. On January 16, 2024, Bacca conducted a wellness check at the couple's private residence due to concerns surrounding their well being. Upon arrival, Bacca observed and photographed the Coroner's seal affixed to the door of the couple's private residence. Licensing Program Analyst conducted an exit interview with Interim Executive Director Kathleen Olson and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 12, 2024