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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005351
Report Date: 05/06/2024
Date Signed: 05/06/2024 11:47:40 AM


Document Has Been Signed on 05/06/2024 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VIEJOFACILITY NUMBER:
306005351
ADMINISTRATOR:FOUDIL MANADIFACILITY TYPE:
740
ADDRESS:27783 CENTER DRIVETELEPHONE:
(949) 364-6210
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:150CENSUS: 102DATE:
05/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Alishia PerezTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports dated 04/24/2024 and 04/28/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Incident report dated 04/24/2024 indicated Staff 1 (S1) witnessed S2 driving the staff's fist into Resident 1's (R1) stomach. Incident report dated 04/28/2024 indicated R1 had reported to family that S2 had punched the resident three times in the stomach. Resident was assessed to have no injuries. OC Sheriff was called and responded with case numbers #24-014481 and 24-014879. Staff 2 was immediately put on suspension pending investigation. During the visit, LPA interviewed three staff and one out of three confirm the incident. Per physician report dated 08/25/2023, Resident is diagnosed with Dementia. The investigation remains ongoing.






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







SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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