306004564-5-9-2025-22-AS-AORZ-DGQT9F-20250516143153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004564
Report Date: 05/09/2025
Date Signed: 05/09/2025 11:47:18 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
02/22/2024 and conducted by Evaluator Fred Arias

COMPLAINT CONTROL NUMBER: 22-AS-20240222162617

FACILITY NAME:	IVY PARK AT HUNTINGTON BEACH		FACILITY NUMBER:	306004564
ADMINISTRATOR:	FREDERICK M. PAOLI		FACILITY TYPE:	740
ADDRESS:	7401 & 7351 YORKTOWN AVE		TELEPHONE:	(714) 536-3032
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92648
CAPACITY:	0	CENSUS:	DATE:	05/09/2025
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Bryan Reamer		TIME COMPLETED:	12:01 PM

ALLEGATION(S):

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Staff did not prevent a visitor from handling resident in a rough manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint inspection to continue an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged staff did not prevent a visitor from handling resident in a rough manner. LPA conducted interviews with residents in care and staff. LPA reviewed resident and staff records obtained.

The investigation determined as follows: regarding the allegation staff did not prevent a visitor from handling resident in a rough manner, it was reported on 02/13/2024 resident 1 (R1) was grabbed by R1’s son and pulled away from a rocking chair.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Fred Arias	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025

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-20240222162617

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 PARK AT HUNTINGTON BEACH	FACILITY NUMBER: 306004564
	VISIT DATE: 05/09/2025

NARRATIVE

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LPA interviews with staff on 05/02/2025 revealed that three out of three staff are aware of mandated reporting requirements and know the steps needed to report resident abuse including stopping and separating individuals who abuse residents and reporting abuse to their supervisors and or the Department. Three out of three staff knew R1 and R1’s son and never witnessed any aggressive behavior from son towards R1. LPA interviews with two out of two residents did not reveal any information regarding the incident or relationship between R1 and R1’s son. LPA reviewed R1’s business and medical records and did not find an incident report from the date of the alleged incident nor any medical record of R1 sustaining an injury on the date the alleged incident occurred. LPA reviewed mandated reporting training records for two out of two staff.

Therefore based on interviews and record reviews, the allegation of staff did not prevent a visitor from handling resident in a rough manner is deemed unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Fred Arias	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025

LIC9099 (FAS) - (06/04)

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