Inspection Reports for Ivy Park at Laguna Creek

The visit was an unannounced case management visit conducted to review an incident involving a resident who fell and was found lying on the floor covered in feces.

The inspection found no deficiencies. The resident had a fall on 09/21/2025 and was found after about 10 minutes. Staff and the resident reported that the resident sometimes experiences dizziness and does not use the call button for assistance. The resident's care plan did not require additional status checks beyond routine care.

The visit was an unannounced case management inspection triggered by an incident report received on 2025-06-24 regarding a resident (R1) who was discovered missing from the facility on 2025-06-23.

The facility was found to have failed to maintain awareness of the resident's general whereabouts for at least 25 minutes, posing an immediate health, safety, and personal rights risk. This resulted in a Type A deficiency and an immediate civil penalty of $500 was assessed.

The visit was complaint-related, triggered by an incident report about a resident who wandered away from the facility unassisted. The deficiency was substantiated with evidence from interviews and record reviews.

The visit was an unannounced follow-up on a complaint investigation regarding an alleged illegal eviction of a resident. During the investigation, an unrelated deficiency was also discovered.

The complaint alleging illegal eviction was found unsubstantiated. However, the facility was cited for requiring a resident's attorney-in-fact to acquire and pay for third-party one-on-one caregivers, which violates residents' personal rights and poses an immediate personal rights risk.

Complaint #27-AS-20250617103041 alleged illegal eviction of a resident, which was determined to be unsubstantiated after investigation. The resident moved in on 2025-06-02 and moved out on 2025-06-13. Verbal conversations occurred regarding the move-out, but no formal eviction notice was given.

The inspection was an unannounced complaint investigation visit triggered by allegations of illegal eviction and failure to provide medications as needed for a resident.

The investigation included interviews and record reviews and found that the allegations of illegal eviction and medications not being provided as needed were unsubstantiated. No deficiencies were cited, and medications were administered as ordered during the resident's stay.

The complaint involved allegations of illegal eviction and medications not being provided to a resident as needed. The investigation found these allegations unsubstantiated, meaning there was not a preponderance of evidence to prove the violations occurred.

The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing requirements at the facility.

The inspection identified several deficiencies including admission of a resident with a pressure wound without appropriate skilled medical supervision, unsecured hazardous materials accessible to residents, improper medication storage, and failure to document routine annual medical visits for residents.

The visit was an unannounced case management inspection triggered by a complaint investigation regarding a resident engaged in hazardous wandering and the facility's failure to submit an incident report.

The facility failed to submit a required incident report to the licensing agency concerning a resident who engaged in hazardous wandering and left the community, posing a potential risk to the resident's health, safety, and personal rights. The facility was cited for this violation.

The complaint investigation revealed that a resident (R1) with dementia engaged in hazardous wandering and left the community on 6/3/25. The facility did not submit an incident report to the licensing agency as required. The incident posed a potential health, safety, and personal rights risk to the resident.

The inspection was an unannounced complaint investigation triggered by an allegation that the facility has insufficient staffing to meet resident needs.

Based on interviews, observation, and record review, the allegation of insufficient staffing was found to be unsubstantiated. Staffing schedules and interviews indicated adequate caregiver presence, and no deficiencies were cited. Some residents reported delays in response times, but these were attributed to errors in the call response system.

The complaint alleged insufficient staffing to meet resident needs. The investigation included interviews with 15 staff and 7 residents, review of staffing schedules, resident records, and call response logs. Despite some resident concerns about response times, the evidence did not substantiate the allegation.

The visit was an unannounced case management inspection conducted to review deficiencies related to a medication error incident reported on 2024-11-27.

The facility was cited for failing to assist a resident with self-administered medications as prescribed, resulting in a medication error where a resident received full pills instead of the prescribed half pills on multiple occasions, posing an immediate threat to health and safety.

The inspection was an unannounced complaint investigation triggered by an allegation that a resident fell due to lack of supervision.

Based on interviews, observation, and record review, the allegation was determined to be unsubstantiated. No deficiencies were cited related to the allegation.

The complaint alleged that a resident fell due to lack of supervision. The investigation included interviews with residents, staff, and review of incident reports and medical records. The resident was diagnosed with a spinal fracture after an injury was discovered. Despite the injury, the evidence did not support the allegation of lack of supervision.

Licensing Program Analysts conducted an unannounced annual inspection to evaluate compliance with regulatory requirements.

No deficiencies were cited during the visit. Technical assistance was provided regarding LIC 602s for dementia residents and staff training. The facility met all environmental and safety standards observed during the inspection.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-02-27 regarding insufficient notice of rate increase and other allegations at Ivy Park at Laguna Creek facility.

The investigation substantiated that the facility did not provide sufficient written notice to a resident's responsible party after a rate increase due to a change in level of care. Other allegations including force feeding, failure to inform authorized persons of condition changes, unmet resident needs, refund issues, and telephone answering were unsubstantiated. The facility was cited for failure to provide timely written notice of rate increase.

The complaint investigation was substantiated for the allegation that staff did not provide sufficient notice of rate increase. Other allegations including staff force feeding a resident, failure to inform resident's authorized person of change in condition, failure to meet resident's needs, failure to refund fees according to admission agreement, and failure to answer the facility telephone were unsubstantiated.

The visit was an unannounced case management inspection conducted to investigate a complaint regarding a resident's suspected unwitnessed fall and injury that occurred on 2024-03-30.

The investigation found that the facility failed to submit an incident report to the licensing agency within seven days of the resident's injury and hospital visit, violating reporting requirements.

A complaint investigation was opened on 2024-04-11 after it was revealed that a resident suffered a suspected unwitnessed fall on 2024-03-30 and was hospitalized. The facility did not notify the licensing agency or other agencies as required.

The visit was an unannounced complaint investigation conducted in response to allegations that staff did not administer a resident's medication as prescribed and that the facility does not have sufficient staff to meet residents' needs.

Based on interviews, observation, and record review, the allegations were found to be unsubstantiated. No deficiencies were cited, and residents appeared healthy and clean with care needs being met despite some concerns about staffing levels.

The complaint involved allegations that a former staff member refused to provide PRN medication to a resident and that the facility was understaffed. Interviews with staff, residents, and review of records did not substantiate these allegations. Staffing levels were sometimes perceived as insufficient during busy times, but all care needs were reported as met. Average response times to call pendants were documented for some residents.

The visit was an unannounced case management visit conducted by Licensing Program Analyst Vincent Moleski to discuss reporting requirements and provide technical assistance.

No deficiencies were cited during this visit. An exit interview was held and a copy of the report was left with the resident care coordinator.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-12-27 regarding staff not providing resident medication as needed and other care concerns.

The investigation substantiated the allegation that staff did not provide resident medication as needed, citing missing medication and improper documentation. Other allegations regarding residents being left in bed for extended periods, being left soiled, inadequate meal services, and unmet showering needs were found unsubstantiated.

The complaint investigation was substantiated for the allegation that staff did not provide resident medication as needed. Other allegations about residents being left in bed or soiled for extended periods, inadequate meal services, and unmet showering needs were unsubstantiated.

The visit was an unannounced case management follow-up to an incident report regarding an unwitnessed fall suffered by a resident on September 13.

No deficiencies were cited during this visit. The incident involved a resident who was hospitalized after the fall and later died on September 29, 2023.

The visit was triggered by an incident report of an unwitnessed fall by a resident (R1) on September 13. The resident was hospitalized and returned on hospice, subsequently dying on September 29, 2023.

The visit was an unannounced case management follow-up to verify correction of a deficiency issued during the facility's annual inspection related to a resident's LIC 602 renewal.

No deficiencies were cited during this visit. The facility has made multiple attempts to renew the resident's LIC 602, including contacting the hospital and planning to use a concierge physician due to lack of hospital response.

The visit was an unannounced case management follow-up to investigate several incidents involving resident aggression and other incidents.

No deficiencies were cited during this visit. Interviews were conducted with the administrator, staff, and residents involved in the incidents.

The visit was an unannounced case management inspection regarding an incident report of an unwitnessed resident fall.

No deficiencies were cited during this visit. The Licensing Program Analyst interviewed the administrator and a staff member, and an exit interview was conducted.

The visit was triggered by an incident report describing an unwitnessed resident fall. No deficiencies were found.

The inspection was an unannounced complaint investigation visit triggered by complaints received on 2023-05-23 regarding staff speaking inappropriately in the presence of residents and failure to respond timely to residents' calls, as well as allegations of medication mismanagement.

The investigation found the allegations of inappropriate staff speech and untimely response to residents' calls to be unsubstantiated based on interviews and record reviews. However, the allegation of medication mismanagement was substantiated due to documented medication errors involving residents R1 and R6, including incorrect dosages and failure to properly transfer medication orders.

The complaint investigation was triggered by allegations that staff spoke inappropriately in the presence of residents and did not respond timely to residents' calls, which were found unsubstantiated. Another complaint alleging medication mismanagement was substantiated based on incident reports and interviews.

The inspection was an unannounced annual inspection conducted by Licensing Program Analyst Vincent Moleski to evaluate compliance with regulatory requirements.

The facility was found to have sufficient furnishings, appropriate environmental conditions, and proper safety measures in place. However, a deficiency was cited for failing to ensure a resident with dementia had an annual medical assessment as required.

Unannounced complaint investigation visit conducted in response to allegations that staff did not ensure residents' responsible parties were informed of epidemic outbreaks, did not maintain resident records, and did not properly discard soiled gloves.

The investigation included review of facility and resident records, interviews with staff and residents, and review of outbreak communication. The allegations were determined to be unsubstantiated due to insufficient evidence to prove violations occurred. No deficiencies were cited during this visit.

Complaint investigation was unsubstantiated. Allegations included failure to inform responsible parties of epidemic outbreaks, failure to maintain resident records, and improper disposal of soiled gloves. Evidence reviewed included illness trackers, posted outbreak letters, interviews, and resident records. No violations were substantiated.

The visit was an unannounced case management follow-up to review two incident reports involving residents at the facility.

The inspection found no deficiencies. Incident reports described one resident tipping over in a wheelchair in a van without a seatbelt and another resident walking into the street, with staff following until paramedics arrived.

The visit was triggered by two incident reports: one involving a resident tipping over in a wheelchair in a van without a seatbelt, and another involving a resident walking out into the street. No deficiencies were cited.

The visit was an unannounced case management inspection conducted to evaluate the facility's compliance with maintenance and sanitation regulations.

During the inspection, live and dead cockroaches were observed in room F15, which is used for storage of activity supplies. The facility was cited for failing to maintain a clean and sanitary environment as required by regulation.

The visit was an unannounced case management follow-up conducted after an incident report involving a resident calling 911 during mealtime.

No deficiencies were cited during the visit. The resident did not express any concerns regarding facility staff or staffing levels, and the incident was reviewed with staff and documentation.

The visit followed up on an incident where a resident called 911 stating they were not feeling well. Staff reported no prior signs or symptoms, and the resident was treated and discharged the same day with no new orders.

An unannounced complaint investigation was conducted due to an allegation that facility staff mishandled a resident's medication.

The investigation found that a resident's medication dosage was increased without a physician's authorization on file, substantiating the complaint of medication mishandling.

The complaint alleging facility staff mishandling resident’s medication was substantiated based on review of medication administration records and doctor’s orders, and interviews with the administrator.

The visit was an unannounced case management inspection regarding an incident report received by licensing about a resident (R1) not being given medication according to doctor's orders.

The inspection found that R1's medication administration records showed the resident started dementia medication at a higher dose than ordered for the initial two weeks, indicating non-compliance with doctor's orders. The facility was cited for failing to assist residents with self-administered medications as required.

The visit was complaint-related due to an incident report alleging that resident R1 was not given medication in accordance with doctor's orders. The allegation was substantiated by review of medication administration records and doctor's orders.

The inspection visit was an unannounced complaint investigation triggered by an allegation that staff were not dispensing medication as prescribed.

The investigation found that staff dispensed medication at a greater milligram strength than prescribed, and resident prescriptions were not filled in a timely manner, resulting in inconsistent medication regimens. The allegations were substantiated and cited under California Code of Regulations.

The complaint was substantiated. Staff dispensed medication incorrectly, including giving a higher milligram strength than prescribed, and prescriptions were not refilled timely, affecting residents' medication regimens.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-03-30 regarding staff not answering residents' call buttons timely.

The investigation found that staff did not respond to residents' call buttons in a timely manner, with delays ranging from 20 minutes to 2 hours, including during an emergency medical occurrence. The facility failed to meet the required response times, posing a potential health and safety risk to residents.

The complaint was substantiated. The allegation was that staff were not answering residents' call buttons timely, which was confirmed by interviews, witness statements, and record reviews.

An unannounced Required 1 Year Annual Inspection visit was conducted to evaluate compliance with Community Care Licensing regulations.

The inspection found no deficiencies cited from California Code of regulations, Title 22. The facility was observed to have proper medication storage, adequate food supplies, functioning safety equipment, and all required resident and personnel records in order.

The visit was an unannounced Case Management inspection conducted regarding untimely reporting of resident deaths and incidents to Community Care Licensing (CCL).

The facility failed to submit required Special Incident Reports (SIRs) and Death Reports to CCL in a timely manner, posing a potential health and safety risk to residents. Two resident deaths were reported late, and a fall incident was not reported as required.

An unannounced complaint investigation was conducted in response to an allegation that the facility was not following COVID protocols.

The investigation found that COVID-related cases had mostly cleared except for one resident, sufficient PPE was available, and all staff and visitors were observed using masks with signage posted. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated based on interviews, observations, and lack of evidence. No deficiencies were cited per California Code of Regulations.

The visit was conducted to investigate a complaint received on 07/30/2021 regarding management not notifying the resident representative about a rent change and not adhering to the admission agreement.

The investigation found that the facility maintained lease agreement guidelines and adhered to the agreement with accurate fees. Staff interviews confirmed that no unauthorized initial fees were charged. The allegations were deemed unfounded due to insufficient evidence.

The complaint was investigated and found to be unfounded based on the preponderance of evidence standard.

Unannounced complaint visit to investigate allegations including unexplained bruising, malnutrition, and pressure injuries sustained by residents while in care.

The investigation found that although the allegations may have happened, there was not a preponderance of evidence to prove the alleged violations occurred. No deficiencies were observed or cited, and the complaint was determined to be unsubstantiated.

Complaint investigation was unannounced and conducted due to allegations of unexplained bruising, malnutrition, and pressure injuries. The findings were unsubstantiated based on medical record reviews and interviews.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 07/30/2021 regarding management not notifying the resident representative about a rent change and not adhering to the admission agreement.

The investigation found that the facility maintained lease agreement guidelines and adhered to the admission agreement. Fees were accurate and no unauthorized initial fees were charged. The allegations were deemed unfounded due to insufficient evidence.

The complaint was investigated and found to be unfounded as the preponderance of evidence standards were not met.

An unannounced annual inspection visit was conducted to evaluate compliance with licensing regulations and assess the facility's operations and conditions.

The inspection found deficiencies including medication administration logging errors, facility cleanliness issues such as cobwebs, bugs, and stained carpets, and a smoke detector in disrepair. Some areas were in compliance, such as the memory care cottage and first aid kit contents.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2020-12-03 regarding cleanliness of a resident's room and mattress, and staff not meeting resident hygiene needs.

The investigation found that the facility failed to ensure the resident's room was properly cleaned and fixtures replaced before moving the resident in. The resident's mattress was damaged from urine, and the room had water damage and a broken towel rack. Some allegations were substantiated, including failure to maintain safe and clean accommodations, while others related to hygiene needs were unsubstantiated.

The complaint investigation was substantiated for failure to maintain clean and safe accommodations and protect resident property. Some allegations related to hygiene needs were unsubstantiated. The investigation included interviews, record reviews, and observations.

An unannounced complaint investigation visit was conducted in response to allegations that facility staff did not assist in transferring a resident as needed and that the facility did not ensure the resident's room was clean.

The investigation substantiated that resident R1 was not assisted with transfers as required by her service plan, resulting in confinement to bed except for showering. Additionally, the resident's room was found to be unclean with stained carpets and debris, and the facility lacked maintenance records for cleaning services.

The complaint investigation was substantiated based on evidence that the facility staff did not assist resident R1 with transfers as needed and did not maintain cleanliness of the resident's room. The preponderance of evidence standard was met and the allegations were substantiated.

Unannounced complaint investigation visit conducted to investigate allegations that the facility did not administer medications as prescribed, did not notify responsible party of medication refusals, and staff were not following training to provide effective services to a resident with dementia.

The investigation found that when the resident refused medications, the facility notified the resident's medical power of attorney and attempted various techniques to administer medications, including redirection and calling the resident's daughter. The complaint was determined to be unfounded as the allegations were false or without reasonable basis.

Complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.

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