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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006222
Report Date: 05/24/2023
Date Signed: 05/30/2023 01:22:20 PM


Document Has Been Signed on 05/30/2023 01:22 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 AT WELLINGTON, THEFACILITY NUMBER:
306006222
ADMINISTRATOR:OLSON, KATHLEENFACILITY TYPE:
740
ADDRESS:24903 MOULTON PARKWAYTELEPHONE:
(949) 458-2311
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92653
CAPACITY:305CENSUS: 117DATE:
05/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gerald "Gerry" VadnaisTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an announced visit for the purpose of conducting a Pre-Licensing inspection. LPA met with Designated Executive Director Gerald "Gerry" Vadnais.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) for a capacity of 305, 115 Ambulatory, 174 non-Ambulatory and 16 bedridden, was submitted to CCL on 08/15/2022.
This is a five story facility with Assisted Living (AL) and Independent Living (IL). LPA inspected the AL and all common areas located on the 2nd floor. The following common areas were observed: Conference Room, Fitness, Health Services, Beauty Salon, Card Room, Bistro, Staff Break Room, Arts/Crafts, Grand Parlor, bathrooms, locked swimming pool, and Club House. The Mail Room, Computer Room, Kitchen, Dining Room, and the Employee Office were inspected on the 4th floor. There are a total of 117 AL apartments. Random apartments were inspected on the different levels. Resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Most residents furnish their own apartments. Residents apartment are equipped with an electric four burner stove, single oven, refrigerator/freezer, dish washer, washer, and dryer are clean and noted to be operational. Resident bathrooms were checked. Toilets and water faucets worked properly and grab bars were secure. Hot water temperature is within regulatory requirements. Perishable and non-perishable food supplies were checked and adequately stocked. Facility has ample back-up emergency food and water supply. A fire clearance was granted on 01/12/2023. A call system is in place. Fire Extinguishers were mounted and fully charged. Smoke detectors and carbon monoxide alert systems are hardwired and tested by outside vendor. LPA observed a courtyard with a putting green. There was shading and sufficient seating for residents, and the walkways around the facility were clear of hazards.
Designated Executive Director has completed a Component III. Component III will be waived on today’s visit.

All elements verified by LPA appear to be in compliance and the facility is ready to be licensed. The license will be granted upon completion of a final review and approval from the Application Specialist. An exit interview was conducted and a copy of this report will be sent to the email on file.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
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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