Inspection Reports for Ivy Park at Otay Ranch

An unannounced Case Management Visit was conducted to deliver an amended complaint report and discuss the purpose of the visit with the Resident Care Coordinator.

No deficiencies were cited or observed during this visit. An exit interview was conducted and the facility representative was provided with a copy of the report and appeal rights.

The visit was related to an amended complaint report; the original complaint report findings were delivered on September 11, 2025.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not prevent a resident from eloping from the facility.

The investigation substantiated the allegation that staff failed to prevent Resident 1 from eloping on September 2, 2025. Resident 1 was found approximately three blocks from the facility after being outside unsupervised for about two hours. A plan of correction was developed to address the deficiency.

The complaint alleged that staff did not prevent Resident 1 from eloping from the facility. The allegation was substantiated based on evidence including interviews, records review, and observations. Resident 1 has a diagnosis of Major neurocognitive disorder and requires supervision. The resident eloped on September 2, 2025 and was missing for several hours before being found.

An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements and assess the facility's condition and operations.

The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited. All required safety equipment, furnishings, and supplies were present and in working order. Staff and resident records were reviewed and found to be complete and properly stored.

An unannounced Case Management Visit was conducted to cite a deficiency identified during a separate complaint investigation.

One deficiency was cited for failure of the licensee or their designated representative to co-sign the admissions agreement for one resident within seven days after move-in, posing a potential personal rights violation.

The visit was triggered by a deficiency identified during a separate complaint investigation.

The inspection was an unannounced complaint investigation triggered by allegations that staff did not prevent residents from eloping from the facility and did not report incidents to appropriate parties.

The investigation substantiated that two residents eloped from the facility and that staff failed to provide adequate supervision and failed to report one of the elopements to the licensing agency. One staff member was suspended and later terminated due to inaccurate resident counts during an elopement drill.

The complaint alleged that staff did not prevent Resident 1 and Resident 2 from eloping and did not report these incidents to appropriate parties. The allegations were substantiated based on interviews, records review, and observations. Resident 1 eloped from the memory care unit and was found after approximately 10 minutes. Resident 2 eloped multiple times and one elopement was not reported to the licensing agency.

An unannounced complaint investigation was conducted regarding an allegation that a resident sustained an injury due to lack of supervision.

The investigation found that the resident and staff involved in the allegation were not associated with the facility, and the complaint was generated in error. The complaint was determined to be unfounded.

The complaint alleged that a resident sustained an injury due to lack of supervision, with incidents on October 21st and 22nd resulting in a head injury. The investigation revealed the resident did not reside at the facility and the staff member did not work there. The complaint was found to be unfounded.

An unannounced complaint investigation was conducted in response to allegations received on 07/29/2024 regarding financial abuse of a resident, improper placement of a resident without dementia in the memory care unit, and staff instructing residents not to use their call pendants.

The investigation found no evidence to substantiate the allegations. Billing records showed no fraudulent charges for multiple apartments, the resident had a documented dementia diagnosis justifying placement in the memory care unit, and call pendants are not used in the memory care bedrooms, so no instruction to avoid their use was found.

The complaint included allegations of financial abuse, improper resident placement, and staff instructions regarding call pendants. The investigation was unannounced and included observations, record reviews, and interviews. The allegations were found unsubstantiated based on evidence including billing invoices, physician's reports, and staff and family interviews.

An unannounced required annual inspection was conducted to evaluate the facility's compliance with licensing requirements.

The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited. Resident rooms and common areas met all regulatory standards, and required safety equipment and postings were present and functional.

An unannounced complaint investigation was conducted in response to allegations of staff neglect resulting in hospitalization and failure to provide incontinence care at the facility.

The investigation substantiated that staff neglected a resident resulting in hospitalization due to delayed response to call buttons and insufficient personal assistance. Another allegation regarding failure to provide incontinence care was unsubstantiated based on evidence from facility and outside agency records. Staffing issues and long wait times for care were noted, but improvements were reported by the Executive Director.

The complaint investigation was substantiated for staff neglect resulting in hospitalization of Resident 1 due to delayed response to calls. The allegation that staff did not provide incontinence care to Resident 2 was unsubstantiated based on review of records and observations.

An unannounced complaint investigation visit was conducted following allegations of neglect/lack of supervision resulting in a resident sustaining a head injury and failure of the licensee to address the resident's change in condition.

The investigation found that Resident #1, a non-ambulatory fall risk, had two unwitnessed falls resulting in injury. Staff conducted increased wellness checks and summoned medical attention promptly. There was insufficient evidence to substantiate neglect or failure to address the resident's change in condition, and the allegations were unsubstantiated.

The complaint was unsubstantiated. Allegations included neglect/lack of supervision causing a head injury and failure to address a resident's change in condition. Investigations included interviews and record reviews confirming increased monitoring and medical response. No evidence supported the allegations.

The visit was initiated due to a self-reported incident involving possible abuse of Resident #1 (R1).

No immediate health and/or safety concerns were observed during the visit, and no deficiencies were cited.

The visit was complaint-related due to a self-reported incident involving possible abuse of Resident #1 (R1).

The visit was an unannounced Case Management Visit in response to a self-reported incident involving a resident who suffered a fall and hit their head.

The Licensing Program Analyst interviewed staff and reviewed facility records. The resident remained hospitalized at the time of the visit. No deficiencies were cited or observed during this visit.

The visit was conducted in response to two SOC341 Reports of Suspected Dependent Adult/Elder Abuse involving theft of cash from Resident #1's wallet, which the licensee self-reported to the Community Care Licensing Division.

The investigation found that staff member S1 did not ensure protection of Resident #1 from theft, resulting in one deficiency cited for violation of personal rights. A Plan of Correction was developed jointly with the licensee. Additionally, one Technical Violation was issued regarding delayed-egress door signs.

The visit was complaint-related, triggered by two reports of suspected theft of cash from Resident #1's wallet, with the first incident involving $300 stolen between 11/21/2023 and 12/06/2023, and the second involving $250 stolen between 01/29/2024 and 01/31/2024. Resident #1 was unable to be interviewed due to passing away on 02/09/2024. The first theft was substantiated with evidence implicating staff member S1; the second theft investigation did not reveal any breakthrough.

An unannounced complaint investigation was conducted due to an allegation that a resident sustained injuries due to lack of care from staff.

The investigation found that the resident had an unwitnessed fall and bruising, but hospital records and staff interviews indicated no new injuries or medication issues. The allegation was unsubstantiated as the evidence did not support lack of care by staff.

The complaint alleged that a resident sustained injuries due to lack of care from staff. The investigation included records review and interviews with staff and the resident's responsible party. The allegation was found unsubstantiated.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 2021-10-11 alleging insufficient staffing to meet residents' needs.

The investigation substantiated that staffing was insufficient to meet resident needs, with documented delays in responding to call alerts, including some taking over 20 minutes and one incident where a resident waited 45 minutes for assistance, requiring emergency intervention.

The complaint alleged that staffing was not sufficient to meet residents' needs. The investigation found substantiated evidence that staffing levels were inadequate, resulting in delayed responses to call alerts and potential risk to resident health and safety.

An unannounced complaint investigation was conducted in response to allegations that facility staff were not adequately trained and mismanaged residents' medications.

The investigation included direct observation, records review, and staff interviews. Training records of three staff members and medication records of three residents were reviewed. Interviews with staff and management indicated improvements and proper training. The allegations were found to be unsubstantiated as the evidence did not support the claims.

The complaint alleged inadequate staff training and medication mismanagement. The investigation found that staff had completed appropriate medication training and that medication records and refill processes were properly maintained. The Resident Care Coordinator, previously a concern, had been terminated and improvements were noted after hiring the Health Services Director. The complaint was unsubstantiated.

The visit was conducted in response to a self-submitted SOC341 Report of Suspected Dependent Adult/Elder Abuse involving a resident and staff member.

During the unannounced case management incident visit, the Licensing Program Analyst performed a facility tour, welfare check, reviewed records, and interviewed involved parties. No deficiencies were observed or cited.

The visit was triggered by a report of suspected dependent adult/elder abuse involving Resident #1 and Staff #1. The report was self-submitted by the licensee to the CCLD San Diego Regional Office on 10/26/2023. The complaint was investigated and no deficiencies were found.

An unannounced complaint investigation was conducted due to an allegation that staff did not provide a 60-day notice prior to a rent increase for residents.

The investigation substantiated the allegation that the facility failed to provide a 60-day prior written notice to Resident 1 before a rent increase for July and August 2023. The facility reversed the rent increase for the affected resident and is issuing rent credits and conducting staff training.

The complaint was substantiated. It was found that Resident 1 received a rent increase without the required 60-day prior notice. The facility acknowledged a personnel transition caused the issue and has reversed the rent increase and notified affected residents and their representatives.

An unannounced complaint investigation visit was conducted following a complaint received on 2023-07-27 alleging that staff spoke inappropriately to residents and did not attend to residents' call buttons in a timely manner.

The investigation substantiated that staff spoke inappropriately to residents and that response times to residents' call buttons were excessively long, sometimes up to 1-2 hours, exceeding the facility standard of 15 minutes. Facility management took corrective actions including staff training and reassessment of staffing levels.

The complaint was substantiated based on evidence including interviews, observations, and records review. Allegations included inappropriate staff communication with residents and delayed response to call buttons. Facility management acknowledged issues and implemented corrective actions.

An unannounced complaint investigation visit was conducted following a complaint received on 2022-01-25 alleging that facility staff did not meet a resident's hygiene and incontinence care needs.

The investigation included observations, interviews, and record reviews. The evidence was insufficient to substantiate the allegations, and the complaint was deemed unsubstantiated.

The complaint alleged that staff did not meet resident R1's hygiene needs and incontinence care needs. The investigation found that R1 was observed clean and groomed during visits, and staff accommodated R1's shower schedule and incontinence care needs with flexibility. Staff documented refusals and followed up accordingly. Outside sources indicated no concerns. Therefore, the allegations were unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate allegations that the licensee did not protect residents in care and that staff did not treat residents with dignity.

The investigation included interviews, records review, and facility tour. The allegations were found to be unsubstantiated based on the preponderance of evidence, including physician reports and staff interviews. Residents R1 and R2 had behavioral challenges but no evidence supported the allegations.

The complaint alleged that staff did not treat residents with dignity and that the licensee did not protect residents in care. The investigation found no substantiation for these allegations after interviews and records review.

The visit was an unannounced Case Management - Other visit to deliver an amended LIC9099-D report.

No deficiencies were observed during the visit. An exit interview was conducted and licensee rights were provided to the facility representative.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-11-15 alleging that staff did not distribute residents' medications as prescribed and did not properly supervise a resident.

The investigation substantiated that staff did not distribute medications in accordance with physician directions for one resident, including distribution of discontinued medication to another resident. Another allegation regarding improper supervision of a resident was unsubstantiated. Deficiencies were cited related to medication administration.

The complaint investigation was substantiated for the allegation that staff did not distribute residents' medications as prescribed, including distribution of discontinued medication to Resident 3 on November 2, 2022. The allegation that staff did not properly supervise Resident 4 was unsubstantiated.

An unannounced Required 1-Year Visit was conducted to evaluate the facility's compliance with licensing requirements and infection control protocols.

No deficiencies were cited or observed during the inspection. The Licensing Program Analyst provided technical assistance and evaluated the facility's infection control mitigation plan including disinfection, testing surveillance, screening protocols, and PPE use.

Licensing Program Analyst Carmen Lopez conducted an unannounced collateral visit to the facility to conduct interviews with residents and staff and to obtain relevant documents.

No deficiencies were observed during the visit. An exit interview was conducted and a copy of the report along with Licensee/Appeal Rights was provided to the Executive Director and Evergreen Director.

An unannounced collateral visit was conducted to interview Resident #1 (R1) and discuss the reason for the visit with the Administrator.

No deficiencies were observed during the visit. An exit interview was conducted with the Administrator, and relevant documents were provided and acknowledged via email.

Licensing Program Analysts conducted a Prelicensing/Component III Visit to observe the physical plant for compliance and assess readiness for licensing.

The facility was found to be in compliance with regulations regarding resident accommodations, safety features, food service, medication storage, and physical plant requirements. No deficiencies or violations were noted during the visit.