306006203-12-7-2024-22-AS-AINZ-DBR2RN-20241207163749

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006203
Report Date: 12/07/2024
Date Signed: 12/07/2024 04:38:36 PM

Document Has Been Signed on 12/07/2024 04:38 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IVY PARK AT SAN JUAN CAPISTRANO		FACILITY NUMBER:	306006203
ADMINISTRATOR/ DIRECTOR:	DAVID ALVARADO		FACILITY TYPE:	740
ADDRESS:	32200 DEL OBISPO STREET		TELEPHONE:	(949) 496-8802
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY: 120		CENSUS: 69	DATE:	12/07/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	David Alvarado/Executive Director		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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On 12/7/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with David Alvarado /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (120) elderly adults ages 60 and above, of which (120) can be non-ambulatory and (4) Bed-ridden. The facility has an approved hospice waiver for (15).

The facility is a two-story building with 54 resident rooms on the first floor and 43 resident rooms on the second floor. The first floor has two large living rooms, dining room, activity room and an outdoor garden courtyard with a fountain. The fountain is raised and does not present a hazard to residents. Outside of the dining room there is an outdoor promenade with tables and chairs for residents to sit outside.

LPA Iniguez and the Executive Director toured the physical plant. LPA inspected a total of (6) bedrooms and (6) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 115.5°F to 116.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2024

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
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: 12/07/2024

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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 10/22/24.

A review of (5) residents' service files and (4) staff personnel files was done. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was given to LPA. Facility Annual Fees are not current since 11/30/24. LPA Iniguez provided current amount balance to administrator and PIN number. Per ED payment was sent to CCLD on 10/26/24.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-See D page for details.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to David Alvarado / Executive Director.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/07/2024 04:38 PM - It Cannot Be Edited

Created By: Alfonso Iniguez On 12/07/2024 at 01:24 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK AT SAN JUAN CAPISTRANO	FACILITY NUMBER: 306006203
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87412(a)(13)(B)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having a criminal record clearance on file for 4 staff members which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2024
	Plan of Correction
1 2 3 4	Licensee will ensure all employees have criminal record clearances at all times. Plan of correction will be sent to LPA via email before POC due 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:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Alfonso Iniguez

LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2024

LIC809 (FAS) - (06/04)

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