Inspection Reports for Ivy Park at Laguna Woods
24441 Calle Sonora, Laguna Woods, CA 92637, Laguna Woods, CA, 92637
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent report on September 22, 2025, which was clean and found the facility responded appropriately to a resident’s medical incident. Some earlier complaint investigations were substantiated, notably involving a staff member suspended for theft in April 2025 and a physical altercation between residents that led to removal of the aggressor. Other substantiated issues included failure to provide timely medical attention in December 2024, improper eviction notice procedures in June 2024, and missing signed admission agreements in December 2024; none resulted in fines or license actions. Several complaint investigations were unsubstantiated, including concerns about dietary plans, infection control, and resident care. The facility’s record shows improvement over time, with recent inspections free of deficiencies after addressing earlier administrative and care-related issues.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
75% occupied
Based on a September 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 175
Capacity: 233
Deficiencies: 0
Date: Sep 22, 2025
Visit Reason
This unannounced case management visit was conducted to follow up on an incident reported to Community Care Licensing involving a resident's severe chest pain and breathing difficulty after a fall.
Complaint Details
The visit was triggered by a self-reported incident on August 25, 2025, regarding a resident's severe chest pain and breathing difficulty on August 15, 2025, following a fall on August 13, 2025. The complaint was found to be unsubstantiated as the facility responded appropriately.
Findings
The facility acted appropriately and in a timely manner to address the incident, with no immediate or safety risks observed. No deficiencies were noted during the visit per Title 22 Division 6 of the California Code of Regulations.
Report Facts
Capacity: 233
Census: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zehra Syed | Executive Director | Met with Licensing Program Analyst during the visit and discussed the incident |
| Ruth Martinez | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 233
Deficiencies: 0
Date: Jul 17, 2025
Visit Reason
The visit was conducted to investigate a complaint alleging that staff were not following residents' dietary plans.
Complaint Details
The complaint was received on 2025-02-06 and investigated with an unannounced visit on 2025-07-17. The allegation that staff were not following residents' dietary plans was determined to be unsubstantiated.
Findings
The investigation found that eight out of nine residents interviewed agreed that staff were following or accommodating most of their diet plans and restrictions. One resident's allegation was unsubstantiated due to lack of documented diet restrictions on file. No deficiencies were cited.
Report Facts
Residents interviewed: 9
Residents agreeing staff follow diet plans: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Program Analyst | Conducted the complaint investigation |
| Zehra Syed | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Jennifer Turgeon | Previous Executive Director | Mentioned regarding receipt of resident diet restrictions |
| Jazzmyne Jefferies | Health Service Director | Mentioned regarding receipt of resident diet restrictions |
Inspection Report
Annual Inspection
Census: 155
Capacity: 233
Deficiencies: 0
Date: Jul 9, 2025
Visit Reason
The visit was an unannounced annual required inspection conducted by Licensing Program Analyst Ruth Martinez to evaluate compliance with licensing requirements.
Findings
The inspection found no deficiencies in the areas inspected, including physical plant, medication storage, resident apartments, safety equipment, and recordkeeping. All required components and safety measures were observed to be in place and operational.
Report Facts
Hospice residents: 6
Hospice waiver capacity: 15
Hot water temperature range: 106.8-112.6
Pool fence height: 5.25
Fire extinguisher service date: 2024
Smoke detector last test date: 2025
Emergency drill last date: 2025
Resident files reviewed: 10
Staff files reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zehra Syed | Executive Director | Met with Licensing Program Analyst during inspection |
| Jessica Hernandez | Business Office Director | Met with Licensing Program Analyst and toured facility |
| Ruth Martinez | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 233
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
The visit was an unannounced case management follow-up on an incident report received by the department regarding a theft at a resident's apartment.
Complaint Details
The complaint involved a theft incident reported by a resident's family, substantiated by video footage. The staff member involved was suspended pending investigation, and the resident moved out of the facility.
Findings
The Executive Director received a report of a staff member rummaging through a resident's apartment and holding the resident's belongings. The staff member was identified and suspended pending investigation. The resident decided to move out and requested a refund, which the facility agreed to process. The Executive Director is awaiting further information from the OC Sheriff.
Report Facts
Incident report date: Mar 27, 2025
Resident move-out date: Apr 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Myers | Executive Director | Spoke with Licensing Program Analyst during visit and involved in incident investigation |
| Jessica Hernandez | Business Office Director | Met during the inspection visit |
| Ruth Martinez | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 233
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
The visit was an unannounced case management follow-up on an incident report received by the department regarding a dispute between two residents on 04/02/2025.
Complaint Details
The complaint involved a physical altercation between two residents who are husband and wife. The complaint was substantiated with no injuries to the victim and appropriate actions taken including law enforcement involvement and removal of the aggressor resident.
Findings
The investigation found that Resident R2 slapped Resident R1 during dinner, with no physical injuries noted on R1. Law enforcement was called, and R2 was removed from the premises and later moved to a memory care unit. R1 remained at the facility with no further issues.
Report Facts
Date of incident report: Apr 3, 2025
Date of incident: Apr 2, 2025
Date of resident move-out: Apr 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the unannounced case management visit |
| Brenda Myers | Interim Executive Director | Spoke with Licensing Program Analyst regarding the incident |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 233
Deficiencies: 0
Date: Mar 19, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2025-02-03 regarding staff leaving a resident in soiled diapers/linen for an extended period, not providing water to a resident, and not taking universal precautions to prevent the spread of illness.
Complaint Details
The complaint was unsubstantiated. Allegations included staff leaving a resident in soiled diapers/linen, not providing water, and failing to take universal precautions. The investigation found no evidence to prove or refute these allegations.
Findings
The investigation included resident and facility file reviews, physical plant tour, and interviews. The allegations were found to be unsubstantiated due to lack of preponderance of evidence. Observations showed adequate water supply, proper infection control measures during an illness outbreak, and no evidence supporting the claim that a resident was left in soiled diapers.
Report Facts
Capacity: 233
Census: 137
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Armando J Lucero | Licensing Program Manager | Named in report as Licensing Program Manager |
| Jessica Hernandez | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Jennifer Turgeon | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Capacity: 233
Deficiencies: 1
Date: Dec 16, 2024
Visit Reason
The visit was an unannounced complaint investigation following a complaint received on 10/29/2024 regarding the facility's failure to issue a refund.
Complaint Details
The complaint was substantiated. Residents R1 and R2 signed admission agreements but the facility did not have a binding agreement signed by a representative within seven days. The residents never physically moved in and were charged fees improperly. The investigation included record reviews and staff interviews.
Findings
The allegation that the facility failed to issue a refund was substantiated. It was found that the admission agreement for residents R1 and R2 was not signed by a facility representative within seven days of admission, and the residents never physically moved into their unit. One violation of California Code of Regulations Title 22 was cited.
Deficiencies (1)
Admission agreements were not signed and dated by the licensee or its representative within seven days following admission for residents R1 and R2, constituting an immediate risk to health, safety, and personal rights.
Report Facts
Facility capacity: 233
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Jennifer Turgeon | Executive Director | Facility representative present during the visit and exit interview |
Inspection Report
Complaint Investigation
Census: 144
Capacity: 233
Deficiencies: 1
Date: Dec 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations received on 09/18/2024 regarding failure to seek timely medical attention, failure to follow physician's orders, and failure to provide quality meals at the facility.
Complaint Details
The complaint investigation was triggered by allegations received on 09/18/2024. The first allegation regarding failure to seek timely medical attention was substantiated. The second allegation regarding failure to follow physician's orders was unsubstantiated. The third allegation regarding poor quality meals was unfounded.
Findings
The investigation substantiated that facility staff did not seek timely medical attention for a resident, with a response time of 26 minutes leading to the resident calling 911 and hospitalization. The allegation that staff did not follow physician's orders was unsubstantiated due to lack of evidence. The complaint regarding poor quality meals was unfounded, with observations and resident interviews confirming adequate food quality and variety.
Deficiencies (1)
Failure to immediately telephone 9-1-1 when an injury or other circumstance resulted in an imminent threat to a resident’s health, including an apparent life-threatening medical crisis.
Report Facts
Response time to resident medical pendant call: 26
Capacity: 233
Census: 144
Plan of Correction due date: Dec 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jennifer Turgeon | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Elena Madsen | Administrator | Facility administrator named in report header |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 137
Capacity: 233
Deficiencies: 0
Date: Jul 3, 2024
Visit Reason
This unannounced visit was conducted to complete an annual required inspection of the facility.
Findings
The inspection found no deficiencies in the areas inspected. The facility was observed to be well maintained with adequate food supply, proper medication storage, functional safety equipment, and compliant resident and staff documentation.
Report Facts
Residents on hospice: 6
Ambulatory licensed capacity: 75
Non-ambulatory licensed capacity: 158
Bedridden licensed capacity: 8
Hospice waiver capacity: 15
Pool fence height (feet): 5.08
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the inspection visit |
| Kathleen Olson | Executive Director | Met with Licensing Program Analyst during inspection |
| Jessica Hernandez | Business Office Director | Met with Licensing Program Analyst during inspection |
| Elena Madsen | Administrator | Facility Administrator named in report |
| Armando J Lucero | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 233
Deficiencies: 1
Date: Jun 20, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility did not accept a resident back after hospitalization and did not issue a refund for rent.
Complaint Details
The complaint investigation was substantiated regarding the facility not accepting Resident 1 back after hospitalization due to medication management assessment. The allegation that the facility did not issue a refund was unsubstantiated. The responsible party disagreed with the medication management assessment and was not provided a copy of the new care plan. The facility did not take action to provide the care plan or contact the resident or responsible party.
Findings
The investigation substantiated that the facility did not accept Resident 1 back after hospitalization due to medication management needs and failure to provide the new care plan to the responsible party. The allegation that the facility did not issue a refund for June 2024 was unsubstantiated as the facility is processing the refund within the allowed timeframe. A deficiency was cited for failure to provide a 30-day eviction notice to the resident.
Deficiencies (1)
Eviction Procedures- The licensee did not serve Resident 1 with a 30 day notice to evict the resident, posing an immediate Health and Safety and/or Personal Rights risk to residents in care.
Report Facts
Capacity: 233
Census: 131
Deficiencies cited: 1
Refund timeframe: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Elena Madsen | Executive Director | Met with Licensing Program Analyst during investigation and involved in care plan discussions |
| Sheila Santos | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Original Licensing
Census: 121
Capacity: 233
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
Licensing Program Analyst Ruth Martinez conducted an announced visit to the facility for the purpose of a pre-licensing evaluation to assess readiness for licensure as an Adult Residential Facility for the Elderly.
Findings
The facility was found to be ready for licensure in the areas inspected, with adequate structure, safety systems, supplies, and operational readiness. No deficiencies were noted in the report.
Report Facts
Capacity: 233
Census: 121
Fire clearance date: Apr 4, 2023
Water temperature range: 113.1-116.7
Ambulatory residents capacity: 75
Non-ambulatory residents capacity: 150
Bedridden residents capacity: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elena Madsen | Executive Director/Administrator | Met with Licensing Program Analyst during the visit |
| Ruth Martinez | Licensing Program Analyst | Conducted the announced pre-licensing visit |
| Armando J Lucero | Licensing Program Manager | Named in report header and signature sections |
Inspection Report
Capacity: 233
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
The visit was an office type evaluation related to a Change of Ownership (CHOW) application for the facility.
Findings
The applicant/administrator participated in a COMP II telephone interview to verify identification and confirm understanding of community care facility licensing laws, including facility operation, admission policies, staffing requirements, restrictive health conditions, and general provisions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elena Madsen | Administrator | Participated in COMP II interview and confirmed understanding of licensing laws. |
| Mirella Quaranta | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Stefania Fonteno | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
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