306006203-11-25-2025-22-AS-KSGH-DNS356-20251125165614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006203
Report Date: 11/25/2025
Date Signed: 11/25/2025 04:56:53 PM

Document Has Been Signed on 11/25/2025 04:56 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: 76	DATE:	11/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:51 AM
MET WITH:	David Alvarado, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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	On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry after introducing himself and the purpose of the visit to front desk staff. Executive Director David Alvarado was notified of the visit and was also present on the premises. LPA requested and reviewed the facility's resident census, staff roster, Emergency and Disaster Plan, Infection Control Plan, staff records including initial and annual training records from Relias. A sample of ten staff records and ten resident records were reviewed during the visit. There are 76 residents admitted at the time of the visit, four of which are receiving hospice care. Resident and staff records were confirmed to include all necessary components per Title 22 regulations. The facility is a two-story building organized around multiple courtyards. LPA accompanied by administrator conducted a tour of the interior and exterior of the physical plant. A total of nine units out of a total of 89 were visited and reviewed throughout the facility. Rooms were observed to be equipped with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Bathrooms were observed to be in good repair; and provided with grab bars and clean slip mats. Hot water was measured in a total of nine locations at faucets delivering hot water for grooming purposes. Water was systematically observed to be within the acceptable temperature range, ranging from 106F to 112F. LPA and staff additionally toured the facility kitchen. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Emergency food and water supply observed in the additional dry food storage with expiration dates current. CONTINUED ON FORM LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025

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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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: 11/25/2025

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CONTINUED FROM FORM LIC809
No unsecured medications, cleaning supplies, or sharp items were observed during the walk-through.

There are 43 residents on medication management. Medical assessments were verified to indicate whether residents managing their own medications were safe to do so. No discrepancies observed. Prescriptions and medication on hand verified for four randomly picked residents, two of which are receiving hospice care at the time of the visit. There are two secure medication carts on the premises, one assigned to each level of the building.

Sprinkler system and fire safety systems were inspected on September 17, 2025. Fire extinguishers have been maintained adequately.

For the exterior portion, facility has a one courtyard on each side. The routes of egress were free of tripping hazards and the exit gates were self-latching and functional. Proof of current liability insurance provided and reviewed. Shade and outdoor furniture verified to be present.

Based on the observations conducted on this day, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Kevin Saborit-Guasch
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025

LIC809 (FAS) - (06/04)

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