306006069-3-22-2024-22-AS-CGUZ-D3LVLK-20240322163205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006069
Report Date: 03/22/2024
Date Signed: 03/22/2024 04:32:44 PM

Document Has Been Signed on 03/22/2024 04:32 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 PARK AT BRADFORD		FACILITY NUMBER:	306006069
ADMINISTRATOR:	RUZICA CALABRESE		FACILITY TYPE:	740
ADDRESS:	1180 N BRADFORD AVE		TELEPHONE:	(714) 996-9292
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	136	CENSUS: 109	DATE:	03/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Neha Patel		TIME COMPLETED:	04:45 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Claudia Gutierrez and Rose Ruppert made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs met with Health Services Director (HSD) Neha Patel and explained the purpose of the inspection. Executive Director (ED) Rose Calabrese arrived at 9:30 a.m.

During the inspection LPAs, HSD, and ED conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and observed the following:

The facility consists of a two-story building complex for assisted living and an adjacent one-story building used for Memory Care. Delayed egress was tested and observed to be operational. All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. The facility has three courtyard areas, each with a shaded sitting area. LPAs observed residents in the facility common areas and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 113.7-120.9 F degrees.

LPAs observed emergency disaster plan with means of exiting and emergency phone numbers listed. Food menu and activities calendar were posted and visible. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors are on a sprinkler system and inspected quarterly. Carbon monoxide detectors are located outside every resident bedroom and tested operational. At least two fire extinguishers are located along every hallway in the facility, and were observed to be fully charged with service tags dated October 30, 2023. Kitchen appliances, washer, and dryer were all observed to be operable. Sharps, all and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication room was observed to be locked; however, over-the-counter medication was observed to be in Resident 1’s (R1’s) bathroom cabinet. R1 is diagnosed with dementia per Physician Report (LIC602A); a Deficiency was cited on today’s date. LPA reviewed eight resident files and five staff files. LPA interviewed five residents and five staff.(Cont. LIC809-C)

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK AT BRADFORD	FACILITY NUMBER: 306006069
	VISIT DATE: 03/22/2024

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on the observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/22/2024 04:32 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 PARK AT BRADFORD	FACILITY NUMBER: 306006069
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705

(f) The following shall be stored inacessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plans, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as over-the-counter medication was obsereved to be accessible in a dementia resident's bathroom, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/23/2024
	Plan of Correction
1 2 3 4	HSD immediately removed medication from resident's bathroom and stated staff training will be conducted and proof will be submitted to LPA via email by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

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