306005351-6-16-2025-22-AS-APAO-DHWUNW-20250623154438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005351
Report Date: 06/16/2025
Date Signed: 06/16/2025 03:39:28 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
04/25/2025 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250425081047

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: 120	DATE:	06/16/2025
		UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:	Foudil Manadi, Executive Director		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff is providing an unknown medication causing residents to choke.

Staff harasses resident.

Staff did not inform responsible party of incident.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above as well as to deliver findings. LPA was greeted and granted entry by Executive Director Foudil Manadi after stating the purpose of the visit.

The initial investigation visit took place on May 1, 2025. During the visit, LPA requested and obtained the facility's current resident census, the employee roster as well as resident records for a total of five currently admitted residents, including their physician reports and charting notes. A tour of the assisted living medication room was conducted along with a review of the centrally stored medication and medication administration records. Two staff interviews and one resident interview also took place.

Four additional staff interviews were conducted during the follow-up visit.
CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

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-20250425081047

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: 06/16/2025

NARRATIVE

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CONTINUED FROM FORM LIC9099
Regarding the allegation that Staff is providing an unknown medication causing residents to choke, the following has been concluded: Based on a review of resident records for a random selection of five residents along with a review of medication on hand in the medication central storage, it was verified that all medication administered to residents under medication management by staff had been adequately prescribed and were adequately labelled. No evidence of additional medication not under physician orders was found during the investigation.

Regarding the allegation that Staff harasses resident, the following has been concluded: A resident interview conducted with the alleged victim of staff harassment conducted in a confidential manner did not evidence any actual instance of harassment. Resident interviewed made statements to the contrary and told LPA that staff was treating them well. Witness interviews were attempted and did not bring forward any evidence of harassment either.

Regarding the allegation that Staff did not inform responsible party of incident, the following has been concluded: Charting notes reviewed for five random residents failed to provide evidence of incidents that had failed to be reported to the appropriate responsible parties. Fall incidents for resident R1 were adequately documented as well as reported to the Department and the resident's responsible party as required. All other instances observed in the charting notes were also reported adequately as confirmed by fax receipts present on file.

Based on the evidence gathered during the present investigation, all three allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred.

An exit interview was conducted with the facility and a copy of the report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC9099 (FAS) - (06/04)

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