Inspection Reports for The Ivy at Wellington
24903 Moulton Pkwy, Laguna Woods, CA 92653, Laguna Woods, CA, 92653
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. The facility’s annual inspection on June 18, 2025, was clean with no deficiencies noted. However, earlier complaint investigations in January 2025 substantiated medication management issues, including administering unauthorized medications and failing to provide prescribed medications, which posed health risks and were not properly reported. These medication-related deficiencies represent the most serious findings in the record, but more recent inspections show improvement with no new deficiencies reported. Other complaints about supervision, food quality, infection control, and resident care were investigated and found unsubstantiated or unfounded.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
68% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
41% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 124
Capacity: 305
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
This unannounced inspection was conducted to investigate complaints alleging lack of supervision resulting in resident on resident sexual abuse and that the facility was allowing a resident to violate the gun policy.
Complaint Details
The complaint investigation was triggered by allegations that lack of supervision resulted in resident on resident sexual abuse and that the facility allowed a resident to violate the gun policy. The investigation included interviews, record reviews, and inspections. The allegations were found to be unfounded.
Findings
The investigation found no corroborating evidence to support the allegations. The facility staff and administration had no reason to suspect abuse, and the facility enforced its gun policy once aware of the violation. The allegations were determined to be unfounded.
Report Facts
Facility capacity: 305
Census: 124
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Gerry Vadnais | Senior Executive Director | Facility representative met during inspection and exit interview |
| Lourdes Montoya | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 305
Deficiencies: 0
Date: Jul 24, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-06-03 regarding staff tampering with resident's personal belongings, not following the monthly menu, and serving poor quality food.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff tampering with resident belongings, failure to follow the monthly menu, and serving poor quality food. Interviews with staff and residents, as well as observations, did not support these allegations.
Findings
The investigation included interviews, facility file and menu reviews, and physical plant tours. The allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove or refute the claims. Residents and staff interviews indicated no consistent issues with food quality or menu adherence, and no evidence of tampering with personal belongings was confirmed.
Report Facts
Capacity: 305
Census: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gerry Vadnais | Executive Director | Met with during the investigation and named in findings |
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Annual Inspection
Census: 91
Capacity: 305
Deficiencies: 0
Date: Jun 18, 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. The facility was observed to be well maintained with proper safety measures, adequate staffing documentation, and appropriate resident care and environment.
Report Facts
Licensed capacity: 305
Current census: 91
Hospice residents: 7
Fire drill frequency: 4
Fire drill last conducted: May 19, 2025
Fire extinguisher service date: Mar 17, 2025
Sprinkler inspection date: Jun 17, 2025
Smoke detector inspection date: Jun 10, 2025
Pool fence height (ft): 6.08
Number of stairwells: 10
Number of evacuation chairs: 10
Resident files reviewed: 9
Staff files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Melanie Sigar | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
| Gerry Vadnais | Administrator/Director | Facility Administrator/Director named in report |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 305
Deficiencies: 0
Date: Apr 8, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2025-03-24 regarding staff discarding residents' meals and dispensing medication not prescribed.
Complaint Details
The complaint was investigated and found to be unfounded; the allegations were false or could not have happened.
Findings
The investigation determined that the complaint was filed under the wrong facility license number and found the allegations to be unfounded, meaning the allegations were false or without reasonable basis. The complaint was dismissed.
Report Facts
Capacity: 305
Census: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Gerry Vadnais | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 305
Deficiencies: 0
Date: Apr 8, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the facility did not release resident records to the responsible party.
Complaint Details
The complaint alleged that the facility did not release Resident 1's records to the responsible party. Staff interviews indicated no knowledge of denial of records, and record review showed documentation was present. Due to conflicting information, the allegation was unsubstantiated.
Findings
The investigation found conflicting information from staff interviews and record reviews, and was unable to determine if the facility failed to release resident records. Therefore, the allegation was unsubstantiated.
Report Facts
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Gerry Vadnais | Executive Director | Facility administrator met during the investigation |
Inspection Report
Census: 117
Capacity: 305
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
An unannounced visit was made by Licensing Program Analyst Andrea Mendivil to deliver an amended report due to technical difficulties in delivering findings earlier.
Findings
The amended report findings were discussed with facility staff including the Health Services Director and Executive Director, and an exit interview was conducted with facility staff.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Made the unannounced visit and delivered the amended report findings. |
| Marites Meneses | Health Services Director | Discussed amended report findings with Licensing Program Analyst. |
| Gerry Vadnais | Executive Director | Discussed amended report findings with Licensing Program Analyst. |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 305
Deficiencies: 2
Date: Jan 9, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-01-02 regarding allegations that the facility administered unauthorized medications and did not provide medications as prescribed.
Complaint Details
The complaint was substantiated. The allegations that the facility administered unauthorized medications and did not provide medications as prescribed were found valid based on records and interviews.
Findings
The investigation substantiated the allegations that the facility administered unauthorized medications to Resident 1 and failed to provide prescribed medications from 12/29/2023 to 02/09/2024. The facility also failed to meet reporting requirements related to these medication issues.
Deficiencies (2)
Facility provided Resident 1 with medication that was not authorized after being discontinued by current physician, posing immediate health and safety risks.
Facility failed to assist residents with self-administered medications as needed, evidenced by Resident 1 not receiving prescription medications from 12/29/2023 to 02/09/2024.
Report Facts
Capacity: 305
Census: 117
Plan of Correction Due Date: Jan 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Gerry Vadnais | Executive Director | Facility administrator who granted entry and was involved in the investigation |
| Marites Meneses | Healthcare Director | Interviewed during investigation regarding medication administration |
| Alisa Ortiz | Licensing Program Manager | Oversaw licensing program and cited deficiencies |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 305
Deficiencies: 1
Date: Jan 9, 2025
Visit Reason
An unannounced case management visit was conducted in conjunction with complaint control 22-AS-20250102131745 regarding allegations that a resident was administered unauthorized medications.
Complaint Details
Complaint investigation related to unauthorized medication administration to Resident 1 (R1). The issue was substantiated based on interviews and record reviews.
Findings
The investigation found that medication Oxybutynin was supposed to be tapered off and discontinued per the current physician's order received on 07/19/2023, but the medication continued to be administered until August 14, 2024, due to a failure to update the medication administration records and report the issue to the Department.
Deficiencies (1)
Failure to report medication issue to the Department, posing potential safety risks to persons in care.
Report Facts
Capacity: 305
Census: 117
Plan of Correction Due Date: Jan 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marites Meneses | Health Services Director | Interviewed regarding medication administration and order discrepancies |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 305
Deficiencies: 0
Date: Dec 4, 2024
Visit Reason
This unannounced visit was conducted to investigate a complaint alleging that a resident sustained multiple unexplained bruises while in care.
Complaint Details
The complaint alleged that a resident sustained multiple unexplained bruises while in care. The allegation was unsubstantiated due to lack of evidence.
Findings
The investigation included interviews with staff and the resident, a tour of the resident's bedroom, and a review of resident records. The resident was being treated for edema and was on blood thinner medication, which could cause bruising. No bruising was observed during the visit, and there was insufficient evidence to substantiate the allegation. The complaint was deemed unsubstantiated.
Report Facts
Estimated Days of Completion: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Gerry Vadnais | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 305
Deficiencies: 0
Date: Oct 1, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff do not provide adequate care and supervision for a resident.
Complaint Details
The complaint was investigated and deemed unfounded, meaning the allegation was false, could not have happened, and/or was without a reasonable basis.
Findings
The investigation found that the allegation was unfounded. Resident records and interviews indicated the resident was independent except for bathing assistance, and the facility had made appropriate assessments and care adjustments following the resident's hospitalization.
Report Facts
Complaint Control Number: 22-AS-20240904100619
Capacity: 305
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Alisa Ortiz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 305
Deficiencies: 0
Date: Jun 25, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not following infection control requirements.
Complaint Details
The complaint alleged that staff were not following infection control requirements. After investigation, the allegation was deemed unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included interviews, observations, and document reviews which found that the facility had infection control precautions in place, including mask usage, cleaning protocols, PPE availability, and notification procedures. Despite the allegations, there was insufficient evidence to substantiate the claim, and the complaint was deemed unsubstantiated.
Report Facts
Facility capacity: 305
Census: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenifer Tirre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Gerry Vadnais | Senior Executive Director | Met with Licensing Program Analyst during the investigation |
| Kathleen Olson | Administrator | Facility administrator named in the report |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Annual Inspection
Census: 103
Capacity: 305
Deficiencies: 0
Date: Jun 20, 2024
Visit Reason
The visit was an unannounced annual required inspection conducted by Licensing Program Analyst Ruth Martinez to evaluate compliance with state regulations.
Findings
The inspection found no deficiencies in the areas inspected. The facility was observed to be well-maintained with adequate staffing, proper medication storage, safe physical environment, and compliance with health and safety regulations.
Report Facts
Licensed capacity: 305
Current census: 103
Hospice waiver capacity: 20
Hospice residents present: 4
Pool fence height (feet): 6.08
Fire extinguisher service date: Mar 16, 2024
Smoke and sprinkler system last tested: Apr 3, 2024
Last emergency drill date: May 14, 2024
Hot water temperature range (Fahrenheit): 118.2-120.2
Number of stairwells: 10
Number of evacuation chairs: 10
Resident ambulatory capacity: 115
Resident non-ambulatory capacity: 174
Bedridden resident capacity: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Gerry Vadnais | Senior Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 305
Deficiencies: 0
Date: Nov 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-10-27 alleging that staff do not answer residents' call buttons in a timely manner and do not ensure residents are bathed.
Complaint Details
The complaint was unsubstantiated. The investigation included interviews with 7 staff and residents regarding call button response times and 3 staff interviews plus 4 resident interviews regarding bathing. The average call response time was between twelve to twenty three minutes based on pendant tracking reports. No evidence was found to prove or refute the allegations.
Findings
The investigation found that staff responded to call buttons within thirteen to fifteen minutes on average, with interviews from staff and residents not corroborating the allegations. Bathing schedules were tracked and refusals documented, with residents reporting no concerns. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 305
Census: 111
Complaint received date: Oct 27, 2023
Call response time range (minutes): 13
Call response time range (minutes): 15
Average call response time range (minutes): 12
Average call response time range (minutes): 23
Number of staff interviews on bathing: 3
Number of resident interviews on bathing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Gerry Vadnais | Executive Director | Met with the Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 228
Capacity: 305
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
This unannounced Case Management – Incident inspection was conducted to follow up on a self-reported incident involving a medication error where Resident #1 received twice the prescribed dose of Oxycodone.
Complaint Details
The visit was complaint-related, triggered by a self-reported incident of a medication error involving Resident #1. The medication error was substantiated as the licensee failed to ensure proper assistance with self-administered medications.
Findings
The inspection found that Resident #1 received a medication error but had no adverse reactions. The facility staff took corrective actions including retraining the Medication Technician involved, who later resigned. Deficiencies were cited related to failure to assist with self-administered medications.
Deficiencies (1)
The licensee did not ensure Resident #1 received assistance with self-administered medications due to a medication error, posing a potential health and safety risk.
Report Facts
Deficiency count: 1
Plan of Correction Due Date: Aug 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gerry Vadinais | Administrator | Met with Licensing Program Analyst during inspection and provided information about the incident |
| Carri Collins | Health Services Director | Interviewed during inspection and provided details about the medication error and corrective actions |
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and authored the report |
| Armando J Lucero | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Original Licensing
Census: 117
Capacity: 305
Deficiencies: 0
Date: May 24, 2023
Visit Reason
Licensing Program Analyst Lydia Martinez conducted a pre-licensing inspection visit to evaluate the facility's readiness for initial licensing as a Residential Care Facility for the Elderly (RCFE) with a capacity of 305 residents.
Findings
The inspection found the facility in compliance with regulatory requirements, including adequate resident accommodations, operational appliances, safety systems, and emergency supplies. The facility is ready to be licensed pending final review and approval.
Report Facts
Facility capacity: 305
Current census: 117
Resident apartment types: 115
Resident apartment types: 174
Resident apartment types: 16
Inspection start time: 9
Inspection end time: 12.5
Fire clearance date: Jan 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gerald Vadnais | Designated Executive Director | Met with Licensing Program Analyst during pre-licensing inspection |
| Lydia Martinez | Licensing Program Analyst | Conducted the pre-licensing inspection visit |
Inspection Report
Capacity: 305
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
The visit was an office type evaluation involving the applicant/administrator's participation in COMP II to verify understanding of community care facility licensing laws and regulations.
Findings
The applicant/administrator demonstrated understanding of facility operation, admission policies, staffing requirements and training, restrictive/prohibited health conditions, and general provisions as confirmed by the CAB analyst during the COMP II interview.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Safoora Ahmed | Administrator | Facility administrator participating in COMP II interview |
| Kathleen Olson | Administrator | Participant in COMP II interview |
| Mirella Quaranta | Licensing Program Manager | Named in report as Licensing Program Manager |
| Stefania Fonteno | Licensing Program Analyst | Named in report as Licensing Program Analyst |
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