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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005423
Report Date: 11/29/2023
Date Signed: 11/29/2023 05:04:34 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
11/27/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231127083743
FACILITY NAME:IVY PARK AT TUSTINFACILITY NUMBER:
306005423
ADMINISTRATOR:BRENT BROADHURSTFACILITY TYPE:
740
ADDRESS:12291 S NEWPORT AVETELEPHONE:
(714) 544-5959
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:70CENSUS: 52DATE:
11/29/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Angela Boyd, Health Services Director
Brent Broadhurst, administrator
TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff didn’t administer resident’s medication as prescribed.

Staff didn’t provide resident with toilet paper
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of initiating the investigation into the two allegations listed above. LPA was greeted and granted entry by the facility's Health Services Director after introducing himself and explaining the purpose of the visit. The allegations investigated were also listed to facility staff at the start of the visit.

LPA requested and obtained a copy of the facility's current resident census. Facility records for residents R1, R2 and R3 were also requested and reviewed in addition to the respective Medication Administration Records for all three residents which were also audited during the visit. All records reviewed are found to include all necessary components at the time of the visit. LPA accompanied by facility staff conducted a tour of units #87, #89 and #91 and verified the presence of a sufficient supply of hygiene supplies in each of the units visited. Staff interviews conducted with facility administrator and Health Services Director. Resident interviews were attempted during the tour of the units.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20231127083743
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 TUSTIN
FACILITY NUMBER: 306005423
VISIT DATE: 11/29/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099

Regarding the allegation that Staff didn’t administer resident’s medication as prescribed, the following has been concluded: Based on the audit of print-outs of the Medication Administration Records provided by facility staff and conducted by LPA during the visit, it was confirmed that all prescribed doses of medication had been marked as dispensed by med tech staff. One evening inhaler prescription for resident R3 was shown as having been discontinued starting on November 25, 2023. Administration records showed that the dispensation of the medication was modified accordingly. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

Regarding the allegation that Staff didn’t provide resident with toilet paper, the following has been concluded: Based on a tour of three units of the physical plant conducted in the presence of a member of the facility's staff, it was confirmed that adequate hygiene supplies such as toilet paper, paper towel and incontinence supplies whenever applicable where present in sufficient quantities in each of the units visited. Even though it cannot be fully ruled out that none of the residents ever used up the supply in place, no evidence that facility is not providing hygiene supplies could be found. The allegation is therefore found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
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