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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006018
Report Date: 05/09/2025
Date Signed: 05/09/2025 09:50:56 AM

Substantiated


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
04/14/2025 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250414144229
FACILITY NAME:IVY TERRACE AT SANTA ANAFACILITY NUMBER:
306006018
ADMINISTRATOR:TORRES, JUDITHFACILITY TYPE:
740
ADDRESS:3730 S. GREENVILLE AVENUETELEPHONE:
(714) 641-0959
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY:72CENSUS: 57DATE:
05/09/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Judith TorresTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility did not follow the reporting requirements.
INVESTIGATION FINDINGS:
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On May 9, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to follow up on the investigation into the above allegation and to deliver findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Judith Torres later arrived shortly after to assist with the inspection.

The initial complaint investigation visit was conducted on April 23, 2025. During the visit, LPA conducted a tour of the physical plant, reviewed six staff files, reviewed seven resident files, conducted five staff interviews, conducted seven resident interviews, and collected relevant documents for Resident #1 (R1).

Regarding the allegation that, facility did not follow the reporting requirements, the following has been concluded: Per charting notes for R1, care staff first noted a rash on R1’s back and front torso on January 16, 2025. Staff also noted scratch marks on these areas and R1 reported being itchy in these areas to staff.
CONTINUED ON 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
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 5
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
04/14/2025 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250414144229

FACILITY NAME:IVY TERRACE AT SANTA ANAFACILITY NUMBER:
306006018
ADMINISTRATOR:TORRES, JUDITHFACILITY TYPE:
740
ADDRESS:3730 S. GREENVILLE AVENUETELEPHONE:
(714) 641-0959
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY:72CENSUS: 57DATE:
05/09/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Judith TorresTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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2
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9
Facility staff are not administering medication as prescribed.
INVESTIGATION FINDINGS:
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On May 9, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to follow up on the investigation into the above allegation and to deliver findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Judith Torres arrived shortly after to assist with the inspection.

The initial complaint investigation visit was conducted on April 23, 2024. During the visit, LPA conducted a tour of the physical plant, reviewed six staff files, reviewed seven resident files, conducted five staff interviews, conducted seven resident interviews, and reviewed the medication and medication administration records (MAR) for seven residents.

Regarding the allegation that, facility staff are not administering medication as prescribed, the following has been concluded: CONTINUED ON 9099-C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20250414144229
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 SANTA ANA
FACILITY NUMBER: 306006018
VISIT DATE: 05/09/2025
NARRATIVE
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Based on a review of seven residents’ medication and their MAR, there were no issues observed. LPA observed medications are being administered accurately and doses are recorded correctly on residents MAR. Furthermore, LPA observed that each medication for the seven residents’ medication reviewed have a complete prescription and that their medications are kept in its original container. Resident interviews conducted also revealed that seven out of seven residents receive their medication as prescribed and on time. Seven out of seven residents also reported that they did not have any concerns regarding staff administering medication. Based on the evidence gathered during this investigation, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC9099 (FAS) - (06/04)
Page: 1 of 1
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
04/14/2025 and conducted by Evaluator Brandon Lopez
COMPLAINT CONTROL NUMBER: 22-AS-20250414144229

FACILITY NAME:IVY TERRACE AT SANTA ANAFACILITY NUMBER:
306006018
ADMINISTRATOR:TORRES, JUDITHFACILITY TYPE:
740
ADDRESS:3730 S. GREENVILLE AVENUETELEPHONE:
(714) 641-0959
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY:72CENSUS: 57DATE:
05/09/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Judith TorresTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
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9
Facility staff are not properly trained to administer medication.
INVESTIGATION FINDINGS:
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On May 9, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to follow up on the investigation into the above allegation. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Judith Torres later arrived to assist with the inspection.

The initial complaint investigation visit was conducted on April 23, 2025. During the visit, LPA conducted a tour of the physical plant, reviewed seven resident files, conducted five staff interviews, conducted seven resident interviews, reviewed six staff files, and reviewed the medication training records for six staff that assist with administering medication.

Regarding the allegation that, facility staff are not properly trained to administer medication, the following has been concluded: Medication Technicians (MTs) are the only staff that assist with administering medication to residents. CONTINUED ON 9099-C
Unfounded
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20250414144229
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 SANTA ANA
FACILITY NUMBER: 306006018
VISIT DATE: 05/09/2025
NARRATIVE
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 As of April 23, 2025, the facility currently has six MTs employed. LPA reviewed the in-service Relias training records for the six MTs currently employed by the facility. Based on a review of the six MTs training records, staff have received adequate medication training and are up to date on their annual medication training. Staff interviews conducted also confirmed that staff receive medication training upon hire and annually every year after. Furthermore, resident interviews conducted revealed that seven out of seven residents did not have any concerns about their medication or staff who administer their medication. Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC9099 (FAS) - (06/04)
Page: 1 of 1
Control Number 22-AS-20250414144229
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 SANTA ANA
FACILITY NUMBER: 306006018
VISIT DATE: 05/09/2025
NARRATIVE
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Staff then sent a fax request to R1’s Primary Care Physician (PCP) regarding her condition. R1’s PCP then prescribed an Ivermectin 3 MG tablet to treat R1 with scabies. Per charting notes, R1 received Ivermectin 3 MG tablet to treat her scabies condition on January 25, 2025, February 5, 2025, March 8, 2025, and March 15, 2025. A prescription for Permethrin 5% cream was received from R1’s PCP on 2/5/25 by the facility. Per R1’s PCP, the Permethrin 5% cream was also prescribed to treat R1’s scabies condition. R1 received doses of Permethrin cream to treat her scabies condition on February 6, 2025, February 13, 2025, March 8, 2025, and March 15, 2025. Per the progress notes on March 14, 2025, R1’s hospice nurse confirmed that R1 had a scabies condition. An interview conducted with R1 also confirmed that staff were putting cream on their body for rashes. Seven out of seven staff interviews conducted also confirmed that R1 had a scabies condition and rashes over their body. On today’s visit, LPA was informed that R1 was transported to Fountain Valley hospital on May 8, 2025 due to her rashes condition worsening. Discharge papers from Fountain Valley Hospital revealed that R1 was being treated for scabies. LPA confirmed that the Orange County Regional Office (OCRO) did not receive a Special Incident Report (SIR) for R1’s scabies condition. Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited on the attached 9099D. An exit interview was conducted with Administrator Judith Torres. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 22-AS-20250414144229
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 SANTA ANA
FACILITY NUMBER: 306006018
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2025
Section Cited
CCR
87211(a)(1)(D)
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(a)(1): A written report shall be submitted to the licensing agency…. within seven days…(D) Any incident which threatens the welfare, safety or health of any resident …

The requirement was not evidenced by:
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AD agreed to create a statement of understanding regarding the regulation and will create a plan of action to ensure that Special Incident Reports are submitted to Community Care Licensing. AD will submit the statement of understanding to LPA via email or fax by POC date.
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Based on LPA's observations, interviews, and records reviewed, the facility did not ensure a Special Incident Report was submitted to Community Care Licensing regarding Resident #1 scabies condition, which poses/posed a potential health, safety, and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5