306006017-5-29-2026-22-AS-LMOA-DUULQW-20260608085813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006017
Report Date: 05/29/2026
Date Signed: 05/29/2026 01:04:14 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
02/17/2026 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20260217130330

FACILITY NAME:	IVY TERRACE AT FULLERTON		FACILITY NUMBER:	306006017
ADMINISTRATOR:	JESUS SOTO		FACILITY TYPE:	740
ADDRESS:	1510 E. COMMONWEALTH AVENUE		TELEPHONE:	(657) 551-3355
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY:	72	CENSUS: 40	DATE:	05/29/2026
		UNANNOUNCED	TIME BEGAN:	12:47 PM
MET WITH:	Sam deGuzman		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility did not seek timely medical attention resulting in resident sustaining fractures

INVESTIGATION FINDINGS:

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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Regional Operations Specialist (ROS) Sam deGuzman on behalf of Administrator (AD) Tammie Sampedro and explained the reason for today’s inspection.

The investigation into the allegation that facility did not seek timely medical attention resulting in resident sustaining fractures revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed AD, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) hospital medical records, and R1’s home health medical records.

CONTINUED

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026

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-20260217130330

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 TERRACE AT FULLERTON	FACILITY NUMBER: 306006017
	VISIT DATE: 05/29/2026

NARRATIVE

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It was alleged that R1 was hospitalized for seizures, began complaining of pain on the third day of their hospital stay, was discovered to have hip fractures, and neither the facility, nor R1 due to their dementia, could explain how R1 sustained the fractures which may have been sustained at the facility. When interviewed, AD stated that there were no reports from staff or R1’s home health bath aides or physical therapists of any fall with R1 or any indication from R1’s behavior that they were in pain. Per AD, due to R1’s osteoporosis, the fractures could have occurred spontaneously due to weakened bones, during transport in the ambulance, or at the hospital itself. Three staff interviewed stated they were surprised by R1’s diagnosis, they were unaware of any incidents which could have caused the fractures at the facility, and they did not notice any change in R1’s behavior indicating they were in pain in the days leading up to R1’s hospitalization. Additionally, one of these staff reported that R1’s bed alarm did not register any falls for R1. When interviewed, R1’s responsible party had no concerns about the care R1 received at the facility and noted that the fractures could have been sustained at the hospital, as R1 was transferred between multiple beds at the hospital and R1’s pain was only noted on the third day of their hospitalization. R1’s hospital medical records indicate R1 had hip fractures, but do not discuss how R1 could have sustained these fractures or how long R1 may have had them before they were diagnosed. In addition, R1’s hospital medical records do not indicate that R1 was in pain upon arrival at the hospital. R1’s home health medical records indicate that prior to R1’s hospitalization, home health staff observed R1 sliding forward in their wheelchair at the facility and educated staff on preventing falls from wheelchairs, but contain no information indicating the fractures were sustained at the facility.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation 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. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026

LIC9099 (FAS) - (06/04)

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