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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006019
Report Date: 04/23/2025
Date Signed: 04/23/2025 02:33:23 PM

Document Has Been Signed on 04/23/2025 02:33 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:IVY TERRACE AT GARDEN GROVEFACILITY NUMBER:
306006019
ADMINISTRATOR/
DIRECTOR:		COLEMAN, KYLEFACILITY TYPE:
740
ADDRESS:11848 VALLEY VIEW STREETTELEPHONE:
(419) 247-2800
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY: 72TOTAL ENROLLED CHILDREN: 0CENSUS: 51DATE:
04/23/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Kyle ColemanTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports received by the department. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Incident report dated 04/11/2025 indicated Resident 1 (R1) was observed to be missing in the facility around 11:45 AM. Facility initiated search. Resident was located outside the community on the corner by a visiting Nurse Practitioner. Resident was assessed to be without injury. Facility investigation determined the resident had gone out an exit gate not normally used by staff. Due to ongoing construction, staff had used the gate which may not have been properly locked. The resident was determined to be out of the facility for approximately 15 minutes.

Incident report dated 04/13/2025 indicated the resident had a witnessed fall in the courtyard. Resident complained of shoulder pain and was sent out where shoulder was popped back in place at the hospital. No further concerns with shoulder noted.

Per physician report dated 10/18/2024, R1 is diagnosed with Mild Cognitive Impairment and is not allowed to leave the facility unassisted.

Facility re-assessed resident and is on frequent checks when not in common area.

LPA spoke with R1 during the visit. Resident appeared clean and well taken care of.

Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
Alisa OrtizTELEPHONE: (714) 703-2855
Kimberly LymanTELEPHONE: (714) 795-1497
DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/23/2025 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: IVY TERRACE AT GARDEN GROVE
FACILITY NUMBER: 306006019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2025
Section Cited
CCR
87464(f)(1)

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Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This req is not met as evidenced by:
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Licensee to provide an elopement in-service and forward proof to LPA by POC due date.
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Based on interviews conducted and record review, Licensee failed to ensure care and supervision was provided to R1. R1 eloped out of the facility and was located outside the community. This poses an immediate health and safety risk to residents 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.
Alisa OrtizTELEPHONE: (714) 703-2855
Kimberly LymanTELEPHONE: (714) 795-1497

DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025

LIC809 (FAS) - (06/04)
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