306005423-5-8-2024-22-AS-RMAZ-D53QKG-20240508121418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005423
Report Date: 05/08/2024
Date Signed: 05/08/2024 12:14:31 PM

Document Has Been Signed on 05/08/2024 12:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	BRENT BROADHURST		FACILITY TYPE:	740
ADDRESS:	12291 S NEWPORT AVE		TELEPHONE:	(714) 544-5959
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	70	CENSUS: 49	DATE:	05/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Sandra Acosta-Louer, Executive Director		TIME COMPLETED:	12:45 PM

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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist, LPA explained the nature of the visit. Sandra Acosta-Louer, Executive Director arrived shortly after and met with LPA. Facility is licensed for 70 non-ambulatory residents, of which 27 may be bedridden. Facility has an approved hospice waiver for 12 residents. There are three residents on hospice during today's visit. This facility consists of two main areas. The assisted living and the memory care unit which are protected by delayed egress exits.

LPA Martinez along with Executive Director Sandra Acosta-Louer toured the physical plant of both the assisted living and the memory care unit. LPA observed a bistro adjacent to the main dining room where residents can obtain different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus for both areas and the food offered is varied and healthful. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen. During the tour LPA observed residents involved in an activity as well as a posted activity schedule including games, exercise, and outings at the facility. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room. LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Seven resident bathrooms were tested for water temperature and water temperature measured between 116.2 and 118.2 degrees F in tested

Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/08/2024

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bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA pushed the restroom call button in various resident rooms and response times were under five minutes. LPA observed several residents who appeared clean, and happy. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in a locked storage closet. LPA toured the memory care unit and observed a kitchen/ dining room as well as posted activity schedule for memory care residents. LPA observed residents in the memory care unit with care staff present. LPA tested the delayed egress exits and response times were immediate. Carbon monoxide detectors tested and noted to be operational. Fire extinguishers are fully charged and had a service date of November 10, 2023. Smoke detectors and sprinkler system are tested every six months by an outside agency, and LPA was provided with testing documentation, last testing was done April 30, 2024. Emergency drills are being conducted on every shift with the last drill conducted on April 18, 2024, as well as an elopement drill on April 30, 2024. Outside grounds have ample shaded seating for residents. LPA reviewed five resident files and three staff files. All resident files contained required documentation including updated physician reports and care plans. Staff files contained required documentation including health screens, first aid, and fingerprint clearance.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Executive Director and a copy of this report was provided 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: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

LIC809 (FAS) - (06/04)

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