306005351-6-4-2024-22-AS-AJLO-D6CSRC-20240618140607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005351
Report Date: 06/04/2024
Date Signed: 06/04/2024 02:51:49 PM

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 Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240529163033

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: 105	DATE:	06/04/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Foudhil Manadi, Executive Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Lack of staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to conduct the required 10 day visit to begin the investigation into the allegation listed above. LPA met with Foudhil Manadi, Executive Director, and explained the reason for the visit.

Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which included interviews conducted, tour of the memory care unit and copies of pertinent documents obtained. It is alleged that the facility has a lack of staff in the memory care unit. Records review revealed that at the time of visit the facility census is 105 of that census the memory care units census is 34. The facility roster reflects that the facility has a total of 48 caregivers on board. 24 caregivers are assigned to the memory care unit and an additional 2

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion: 1

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

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-20240529163033

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 MISSION VIEJO	FACILITY NUMBER: 306005351
	VISIT DATE: 06/04/2024

NARRATIVE

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new hires will come on board within this week. The facility staff schedule reflects that there is three shifts per day. Schedule from December 31, 2023 to June 08, 2024 reflect the following on each shift: AM shift has anywhere from 4-7 caregivers, 1 medtech, 1 activity coordinator, and 1 memory care director. PM shift has anywhere from 4-7 caregivers, 1 medtech, and 1 memory care director. NOC shift has anywhere from 2-3 caregivers, and a medtech. All shifts have a nurse on board as well. Interview with Executive Director indicated that all shifts have caregivers, a nurse and a medtech scheduled per shift. Title 22 regulation 87411(a) Personnel Requirements-General states: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment, and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. LPA toured the memory care unit and observed residents in the living room and dinning room. LPA observed 5-6 staff assisting resident with their needs and observed 1 caregiver assisting a resident in their bedroom with hygiene needs. Interview with 2 of 2 staff revealed that they like to staff the memory care unit with a minimum of 4 caregivers on each shift, however the shift has 5-7 caregivers at one time. There are always nurses on board in assisted living and memory care unit that helps as needed when needed. The facility staff are cross trained and everyone at the facility is very hands on and fills in as needed when it is required to do so. The schedule for the memory care unit is always staffed to make sure that each shift is fully staffed.

Based on the information gathered during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

This report was reviewed with Executive Director and a copy was furnished to the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024

LIC9099 (FAS) - (06/04)

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