306005351-1-27-2023-22-AS-LADS-CNTV78-20230207151042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005351
Report Date: 01/27/2023
Date Signed: 01/27/2023 11:23:56 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/20/2023 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230120111554

FACILITY NAME:	IVY PARK AT MISSION VIEJO		FACILITY NUMBER:	306005351
ADMINISTRATOR:	FOUDIL MANADI		FACILITY TYPE:	740
ADDRESS:	27783 CENTER DRIVE		TELEPHONE:	(949) 364-6210
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92692
CAPACITY:	150	CENSUS: 102	DATE:	01/27/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Foudil Manadi		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Facility retaining resident that requires a higher level of care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director (ED) Foudil Manadi and explained the reason for the visit. The investigation into the allegation, facility retaining resident that requires a higher level of care, revealed the following. It was alleged that because Resident 1 (R1) needed staff to operate their oxygen concentrator and continuous positive airway pressure (CPAP) machine they required a higher level of care and the facility was retaining the resident despite this requirement. LPA interviewed ED Manadi and 3 staff members. LPA reviewed R1's, admission agreement, needs and care plan, and the physician's report. The physician's report dated 5/23/19 and facility assessment (needs and care plan dated 1/19/23) show R1 did not require assistance with oxygen administration (oxygen concentrator and CPAP machine) or medication management. It was reported that R1 could not operate the oxygen concentrator and CPAP machine on their own. 3 out of 3 staff interviewed reported R1 could use their oxygen concentrator and CPAP machine unassisted. It was reported that staff assisted R1 with using their oxygen concentrator and CPAP machine because R1 could not operate the equipment unassisted.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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-20230120111554

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: IVY PARK AT MISSION VIEJO	FACILITY NUMBER: 306005351
	VISIT DATE: 01/27/2023

NARRATIVE

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3 out of 3 staff interviewed could not corroborate that report. The ED reported that he met with R1's responsible party (RP) in December 2022 and when the issue came up of assisting R1 with their oxygen concentrator and CPAP machine they suggested a home health aid, hospice, a skilled nursing facility or a private qualified caregiver to assist R1, because of Title 22 regulations they are not allowed to have staff operate the equipment for any resident..The ED reported that no resident who needs a higher level of care is ever retained or forced to stay at the facility. R1 no longer resides at the facility. Based on the evidence gathered through interviews and a review of records the allegation, facility retaining resident that requires a higher level of care is deemed, unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

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