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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603715
Report Date: 06/19/2025
Date Signed: 06/19/2025 03:13:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250616090026
FACILITY NAME:IVY PARK AT SAN MARINOFACILITY NUMBER:
198603715
ADMINISTRATOR:SANCHEZ, KIMBERLYFACILITY TYPE:
740
ADDRESS:8332 HUNTINGTON DRIVETELEPHONE:
(626) 292-7800
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:74CENSUS: 62DATE:
06/19/2025
UNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Leticia Garcia, Health Services DirectorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the allegation listed above. The purpose of the visit was explained to Health Services Director Leticia Garcia.

The investigation consisted of: The physical plant was toured, records were reviewed, and interviews with residents (R1-R9) and staff (S1-S4) was conducted. Resident (R1's) file documents were obtained. Copies of Copies of R1's Face Sheet, Physician's Report, Individual Service Plan, 2 medication physician orders dated 5/30/25, QuickMar charting notes, Medication Administration Records for months May 2025- June 2025, resident roster, and staff roster were obtained. No health and safety concerns were observed.

*See next page.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20250616090026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: IVY PARK AT SAN MARINO
FACILITY NUMBER: 198603715
VISIT DATE: 06/19/2025
NARRATIVE
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Allegation: Staff are mismanaging resident's medication. The complaint alleges the facility failed to obtain two physician orders for blood pressure medication Amlodipine 2.5 mg, and antibiotic Macrobid 100 mg. According to information obtained, resident (R1) ran out of Amlodipine 2.5 mg in early May 2025 and obtained the medication until May 30, 2025. Regarding the antibiotic medication, it is alleged that on May 29, 2025 resident (R1) had symptoms of a urinary tract infection, and staff contacted R1's responsible party and was told that an antibiotic medication would be obtained. Nine residents were interviewed. None reported medication administration issues. A total of four (4) staff were interviewed. Based on interviews conducted, the findings indicate that staff initially contacted R1's pharmacy on 5/11/25 about Amlodipine 2.5 mg refill, but failed to document any follow-up details on Medication Administration Records, and communicate with Administration staff or Health Services Director that staff were having trouble getting a physician order for the medication. In regards to the antibiotic medication staff interviews revealed that R1's responsible party was informed a urine sample order would be requested from the physician. On May 29, 2025, R1's responsible party visited the resident at approximately 5:00 PM, and was told by staff they had not had any communication with R1's doctor about urinalysis or possible antibiotic. On May 30, 2025, physician orders were obtained after R1's responsible party contacted palliative care doctor on their own. QuickMar charting notes do not have any documentation that physician orders were obtained and medications were filled and brought to the facility by R1's responsible party on May 30, 2025. Therefore, there is sufficient evidence to corroborate the allegation.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is cited according to California Code of Regulations, Title 22. See LIC 9099D.

An exit interview was conducted with Health Services Director Leticia Garcia. A copy of the report and appeal rights was issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250616090026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: IVY PARK AT SAN MARINO
FACILITY NUMBER: 198603715
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.
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Health Services Director agreed to submit by tomorrow a written plan of correction that addresses physician orders, charting documentation, and team communication.

Proof of staff training shall be submitted by 6/23/25.
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This requirement was not met evidenced by: Based on record review, R1 ran out of Amlodipine 2.5 mg medication. On 5/11/25, med-tech contacted pharmacy and they sent a 5-day supply. However, from dates May 17, 2025 - May 30, 2025 the medication was not on hand at the facility. This poses an immediate health, safety, and personal rights of the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3