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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006203
Report Date: 04/09/2025
Date Signed: 04/09/2025 06:27:15 PM

Unfounded


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
04/02/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250402084342
FACILITY NAME:IVY PARK AT SAN JUAN CAPISTRANOFACILITY NUMBER:
306006203
ADMINISTRATOR:DAVID ALVARADOFACILITY TYPE:
740
ADDRESS:32200 DEL OBISPO STREETTELEPHONE:
(949) 496-8802
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:120CENSUS: 73DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:David AlvaradoTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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9
Staff did not ensure residents light worked properly
Staff do not ensure medications are properly managed for residents in care

INVESTIGATION FINDINGS:
1
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5
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10
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13
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegations listed above. LPA met with Executive Director David Alvarado and explained the reason for the visit. The investigation into the allegation, staff did not ensure resident's light worked properly revealed the following. It was reported that Resident 1's (R1) kitchen did not have a light. R1's room does not have a kitchen. R1's residence is 1 room with a bathroom and an outdoor patio. There is a small entrance hallway that leads into the 1 room. In the corner of the room next to the bathroom there is a small sink with an overhead cabinet and a cabinet to the left side which has a microwave oven. This area is approximately 6 feet away from R1's bed. The room is lit by a ceiling light in the entry hall by the front door and 2 lamps. Both lamps are the property of R1. Natural light comes into the room through the balcony door which has numerous windows in it. R1 reported that there should be a light above the sink provided by the facility. Staff reported that the if R1 purchased a light for above the sink they could install it for R1 but they declined. The room has 2 lamps that light the room. There is no regulation requirment for a lamp to be mounted under a cabinet.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
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 4
Control Number 22-AS-20250402084342
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 PARK AT SAN JUAN CAPISTRANO
FACILITY NUMBER: 306006203
VISIT DATE: 04/09/2025
NARRATIVE
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The room has lighting and there is no kitchen as the unit is only 1 room. Based on the evidence gathered the allegation is determined to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

The investigation into the allegation, staff do not ensure medications are properly managed for residents in care, revealed the following. It was alleged that the facility does not properly manage residents medication including Resident 1 (R1) who allegedly ran out of their PRN medication (Acetaminophen 500 mg) on or around March 20, 2025. LPA reviewed 7 resident medications records for March and April 2025, including R1's records. LPA observed all medications are secured in the medication room in a medication cart which is kept locked. Medications only leave the medication room under staff supervision when they are being administered to residents. A review of review of records shows R1 did not receive their Acetaminophen 500 mg on March 5, 2025 and March 20, 2025. 4 out of 4 staff members interviewed reported that on those days R1 did not request the Acetaminophen 500 mg which is a PRN medication. R1 reported that they ran out of their PRN Acetaminophen 500 mg on or around March 20, 2025 and had to refill the prescription on their own. R1 did not report missing their medication any other days other than on or around March 20, 2025. 4 out of 4 staff interviewed reported that R1's PRN for Acetaminophen 500mg was recently reordered and they never ran out. A review of R1's records show that the prescription for Acetaminophen 500 mg was refilled on March 26, 2025 and the bottle was first opened on March 26, 2025. The Medication Administration Record (MAR) for R1 for March 2025 shows the only days that the PRN Acetaminophen 500 mg was not administered was March 5, 2025 and March 20, 2025. Since the prescription was filled on March 26, 2025 and there are no other discrepancies reported or noted in the records and R1 received Acetaminophen 500mg PRN each day from March 21 through March 31, R1 never ran out of medication as reported. No discrepancies were observed in 7 out of 7 resident medication records reviewed. LPA interviewed 6 residents. 6 out of 6 residents reported not having any issues with their medications. Based on the evidence gathered the allegation is determined to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
04/02/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250402084342

FACILITY NAME:IVY PARK AT SAN JUAN CAPISTRANOFACILITY NUMBER:
306006203
ADMINISTRATOR:DAVID ALVARADOFACILITY TYPE:
740
ADDRESS:32200 DEL OBISPO STREETTELEPHONE:
(949) 496-8802
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:120CENSUS: 73DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:David AlvaradoTIME COMPLETED:
05:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not ensuring residents room is set up safely
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegations listed above. LPA met with Executive Director David Alvarado and explained the reason for the visit. The investigation into the allegation, staff are not ensuring residents room is set up safely, revealed the following. Resident 1 (R1) changed rooms on March 20, 2025. R1 agreed to changing rooms. Facility staff moved all of R1's belongings to the new room. Facility staff reported that they set up R1's furniture and TV as R1 requested. R1 verified thsi report. Staff reported that they mounted R1's pictures on the wall but R1 took them down, R1 reported that staff would not put up their pictures the way they wanted. Staff reported that R1 did not want staff to put all of her items in the closet or on the dresser. R1 reported that the facility should help put her miscellaneous items away or provide some type shelving for the items. Staff reported they attempted to assist R1 with putting their extra items away but R1 didn't want their items moved. LPA observed that R1 had pictures and bags of clothing stored up against the wall of their room and in the corner by the patio door.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
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 4
Control Number 22-AS-20250402084342
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 PARK AT SAN JUAN CAPISTRANO
FACILITY NUMBER: 306006203
VISIT DATE: 04/09/2025
NARRATIVE
1
2
3
4
5
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11
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 R1 reported the items are where they want. R1 has all of the required furnishings in the room, which R1 provided. The facility is not required to provide additional furniture for storage. There are no trip hazards in the room because there is a clear path to the sink, microwave oven, bathroom, bed, patio door and front door. R1 and the staff reported conflicting information. Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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