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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003765
Report Date: 07/31/2026
Date Signed: 09/14/2026 03:27:32 PM

Document Has Been Signed on 09/14/2026 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:IVY COTTAGES IFACILITY NUMBER:
306003765
ADMINISTRATOR/
DIRECTOR:		CARMEN RODRIGUEZFACILITY TYPE:
740
ADDRESS:9856 MARIPOSA AVENUETELEPHONE:
(714) 965-0412
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
07/31/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Carmen Rodriguez - Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On July 31, 2026, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit. Upon arrival at the facility, LPA Bentley introduced self and was granted entry into the facility by staff, after stating the purpose of the visit. Administrator (AD) Carmen Rodriguez was present and assisted with the inspection. Carmen Rodriguez has an administrator certificate that expires on May 21, 2028.

The facility is licensed to operate for six (6) non-ambulatory residents, with a Hospice waiver for three (3) residents. The building is a single-story home located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, two (2) full bathrooms, living room area, dining area, kitchen, an outdoor covered seating area, and an attached two car garage. The garage is currently under construction, for which the facility has a permit. There are currently six (6) residents on census.

During the visit, LPA toured interior and exterior of the physical plant with AD and the following was observed: There were no bodies of water on the premises. All rooms were inspected and the facility to be sanitary and appropriately furnished at the time of visit. Beds and bedding supplies were in good condition, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. A comfortable temperature of 72 degrees F was maintained in the facility. Bathrooms were found to be clean and operational with water temperatures measured between 110.1 degrees F and 113.3 degrees F. The kitchen was observed clean with all appliances in working order. There is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly.

CONTINUE TO LIC809-C....
Kevin Saborit-Guasch
Eboni Bentley
DATE: 07/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IVY COTTAGES I
FACILITY NUMBER: 306003765
VISIT DATE: 07/31/2026
NARRATIVE
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LPA toured the backyard and observed a shaded seating area with a table and chairs for residents to sit outside. There is one exit gate leading to the front yard where a tent with items transferred from the garage are being stored. A Technical Violation is being provided.

The smoke alarms and carbon monoxide detectors were operable. An emergency safety drill was last conducted on June 5, 2026. First aid kit is maintained and contains all the necessary elements. A working telephone (714)965-0412 remains available and the facility has a device that can be used for video teleconference purposes. Emergency food, water, and supplies were stored in the tent. The facility has one (1) fire extinguisher that was charged, mounted, and serviced on August 12, 2025. Liability Insurance is effective April 30. 2026, and expires on April 30, 2027.

LPA conducted an audit of six (6) resident files (R1-R6), five (5) staff files (S1-S5), and medication and medication administration review. A record review revealed Resident #1 (R1) has a restricted and prohibited health condition that was not reported to the Department.

Based on observations, interviews, and record review, deficiencies are being cited as per Title 22, Division 6, Chapter 9 of the California Code of Regulations.

An exit interview was conducted with Administrator Carmen Rodriguez, and a copy of this report, LIC809-D, LIC811, and appeals rights were provided at the end of the visit.
NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/14/2026 03:27 PM - It Cannot Be Edited


Created By: Eboni Bentley On 07/31/2026 at 02:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY COTTAGES I
FACILITY NUMBER: 306003765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87615
Prohibited Health Conditions 87615(a)(1)
(a) Persons who require health services for or have a health condition including, but not limited to... shall not be admitted or retained... (1) Stage 3 and 4 pressure injuries.

This requirement is not met as evidenced by:
Deficient Practice Statement
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The Department reviewed R1s medical records stating that R1 had a Stage 3 pressure injury since June 16, 2026. Licensee informed LPA that Homelink Home Health is treating the wound and no Hospice care is being provided. This poses an immediate health and safety risk to residents in care.
POC Due Date: 08/01/2026
Plan of Correction
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Licensee stated they will apply for an exception with the Department in an effort to come into compliance and request to doctor order for a Hospice Care from R1's doctor. Licensee will send proof to LPA by POC due date.
Type A
Section Cited
CCR
87613
87613 General Requirements for Restricted Health Conditions (a) Prior to admission of a resident with a restricted health condition, the licensee shall: (1)Communicate with all other persons who provide care to that resident to ensure consistency of care for the condition. (2)Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs.
(A)Training shall include hands-on instruction in both general procedures and resident-specific procedures.
(B)Training shall be completed prior to the staff providing services to the resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not maintain a copy of Resident #1's (R1’s) Home Health care plan resulting in the facility not being able to confirm whether their suprapubic catheter needs were being met by a skilled nursing professional from admission date of 4/22/25 and on a continual basis, which poses an immediatel health risk to persons in care. Training records for 5 out of 5 staff by a skilled nursing professional were not provided during visit.
POC Due Date: 08/01/2026
Plan of Correction
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Licensee stated they will submit a training plan for all staff caring for R1 and request the care plan from Homelink Home Health. Licensee will submit proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/14/2026 03:27 PM - It Cannot Be Edited


Created By: Eboni Bentley On 07/31/2026 at 02:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY COTTAGES I
FACILITY NUMBER: 306003765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
87211(a)(1) Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...
This requirement was not met as evidence by:

Deficient Practice Statement
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Based on Interview and record review, R1 moved in on 4/22/25 with a suprapubic catheter and stage 3 pressure wound. A request for an exception for restricted and prohibitted health condition was not received by the Department, which poses an potential health and safety risk for client in care. A Home Health and Hospice care plan was not provided during the visit.
POC Due Date: 08/07/2026
Plan of Correction
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Licensee stated they will conduct an in service for all staff regarding reporting requirements and submit a statement of understanding to LPA by POC due date. Licensee stated they will obtain and maintain the Plan of Care from R1's admission date and submit proof to LPA by POC due date.
Type B
Section Cited
CCR
87633(a)(2)
87633 Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:..(2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act ... Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not ensure R1 was receiving Hospice care for stage 3 pressure wound and maintain a copy of R1’s hospice care plan resulting in the facility not being able to confirm whether their care needs were being met by hospice, which poses a potential health risk to persons in care.
POC Due Date: 08/07/2026
Plan of Correction
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Licensee stated they will obtain a copy of R1's Hospice Plan of care and agreement, and send with proof training conudcted by a skilled nursing professional for all caregiving staf to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2026


LIC809 (FAS) - (06/04)
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