306003766-5-12-2026-22-AS-AORZ-DUQP7Z-20260604110446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003766
Report Date: 05/12/2026
Date Signed: 05/12/2026 11:13:07 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/29/2024 and conducted by Evaluator RoseMarie Ruppert

COMPLAINT CONTROL NUMBER: 22-AS-20240529100646

FACILITY NAME:	IVY COTTAGES II		FACILITY NUMBER:	306003766
ADMINISTRATOR:	CARMEN RODRIGUEZ		FACILITY TYPE:	740
ADDRESS:	16827 MT. EDEN STREET		TELEPHONE:	(714) 531-2185
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	05/12/2026
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Carmen Rodriguez Licensee		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not seek timely medical care for resident in care
Staff did not provide adequate food service to residents in care
Staff did not provide activities to residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA was greeted and granted entry by staff at 8am. LPA met with Licensee (LE) Carmen Rodriguez and explained the purpose of the visit.

LPA obtained the following documentation for Resident #1 (R1): Emergency and Identification Information, Physician's Report dated 11/27/2023, Appraisal Needs and Services Plan dated 4/20/2024, Preplacement Appraisal Information dated 4/20/2024, Admissions Agreement and Durable Power of Attorney for Finances and Property.

Upon entry LPA observed there were six residents and four staff members present. Two staff members were preparing residents for the day and providing showers. Two staff members were preparing breakfast and feeding residents.
(Continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240529100646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 II	FACILITY NUMBER: 306003766
	VISIT DATE: 05/12/2026

NARRATIVE

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(Continued from LIC 9099)

LPA interviewed two of two staff members who were present in 2024 and two of three residents who resided in the facility in 2024. LPA also attempted to contact three of three witnesses and was unable to contact any of the witnesses.

It was alleged that: Staff did not seek timely medical care for resident in care. LPA interviewed two of two staff regarding the services provided to Resident #1 (R1). R1 moved into the facility from a large assisted living on May 20. 2024.

R1 was non-verbal and, per Physician's Report dated November 27, 2023, R1's diagnosis was Major Neurocognitive Disorder. No skin lesions or wounds were noted on May 20, 2024. Per interview of two of two staff, R1 only had a pink rash but there was no puncturing of the skin. Two of two staff stated they were working on obtaining physical therapy (PT) and occupational therapy (OT) for R1 through insurance but resident passed away seventeen days later. R1 passed away on May 6, 2024 due to cardiac arrest. Fountain Valley Police Department had arrived on scene with paramedics and a photo was taken of the Electrocardiogram that was on file with the date of May 6, 2024 at 1:59pm.

Two of two staff denied the allegations that the facility did not seek timely medical care of R1. Two of three residents interviewed stated they do not have issues with the care being provided. LPA observed the medications and nitroglycerin was provided to the facility upon discharge from the larger assisted living facility. Nitroglycerin was prescribed as needed. Per interview with staff, nitroglycerin was not administered due to the immediate arrival of paramedics; whose proximity is very close the facility.

LPA investigated the allegation that: Staff did not provide adequate food service to residents in care. LPA toured the facility with Licensee (LE) and observed two staff members preparing and feeding breakfast to residents in care. Breakfast consisted of fruit, yogurt, pancakes and oatmeal. Lunch was being prepared in a slow cooker and consisted of pork roast, carrots and potatoes with salad. LPA observed a baked cake prepared on May 11, 2026 for the residents. The pantry had seven days of non-perishable items and the refrigerator had two days of perishable items.

(Continued on LIC 9099-C1)

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240529100646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 II	FACILITY NUMBER: 306003766
	VISIT DATE: 05/12/2026

NARRATIVE

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(Continued from LIC 9099-C)

Interviews with two of two staff stated that R1's spouse visited once or twice a week per Dial-a-Ride and would arrive between 1-2pm. Staff stated R1 would eat approximately 25% of food. Spouse wanted R1 to eat more food but R1 was not responsive to eating an entire meal. Interviews of two of three residents stated they are being fed plenty of food and that they like the food.

It was also alleged that Staff did not provide activities to residents in care. LPA interviewed two of three residents who answered that they participate in activities. Two of two staff also shared with LPA that for the past twenty years, a piano person comes on Thursdays and plays music for the house for approximately one hour. Residents take a daily walk around the block. During the visit LPA observed staff with the six residents in a circle, doing a ball toss and exercise.

Two of two staff reported that when family came to visit R1, it was always after lunch when residents took a nap. Most of the activities occur in the morning between breakfast and lunch. LPA observed various types of activities throughout the facility for staff to engage residents. Two of three residents interviewed participate in activities and liked dancing and music. Later in the afternoon, prior to dinner, activities resumed but family was not present at this time and wanted activities to occur while residents were napping.

Based on LPA's observations, interviews and record review, the allegations that: Staff did not seek timely medical care for resident in care, Staff did not provide adequate food service to residents in care and Staff did not provide activities to residents in care are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Licensee (LE) Carmen Rodriguez, and a copy of this report and LIC 811 was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

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