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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005351
Report Date: 05/06/2024
Date Signed: 05/06/2024 11:49:09 AM

Unfounded


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
05/02/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240502140416
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
UNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Foudil ManadiTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff did not seek timely medical attention for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA interviewed staff as well as reviewed and obtained pertinent documentation such as hospital discharge paperwork. Regarding the allegation that facility staff did not seek timely medical attention for resident, the investigation revealed the following: Facility notes dated 03/22/2024 indicate Resident 1 (R1) was being seen by Nurse Practitioner and started antibiotics and prednisone for coughing/ congestion. Resident was receiving breathing treatments along with medication management as indicated on facility documents. Facility documents indicate R1 was non-compliant with treatments as well. On 03/29/2024, 911 was called due to resident wheezing and difficulty breathing. Resident was admitted to Providence Mission Hospital on 03/29/2024 for Acute Respiratory Failure with Hypoxemia. Resident discharged back to the facility on 04/12/2024 with a Hospice admission diagnosis of Heart Disease. Resident passed on 04/16/2024. CONTINUED ON LIC 9099C DATED 05/06/2024
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
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Control Number 22-AS-20240502140416
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: 05/06/2024
NARRATIVE
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Based on record review and interviews conducted, the department has determined the facility did seek timely medical treatment for the resident. Therefore the allegation is deemed unfounded meaning the allegation is false could not have happened and/or is without a reasonable basis.

Exit interview conducted with Administrator 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
LIC9099 (FAS) - (06/04)
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