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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006222
Report Date: 06/18/2025
Date Signed: 06/18/2025 12:22:44 PM

Document Has Been Signed on 06/18/2025 12:22 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:IVY AT WELLINGTON, THEFACILITY NUMBER:
306006222
ADMINISTRATOR/
DIRECTOR:		VADNAIS, GERRYFACILITY TYPE:
740
ADDRESS:24903 MOULTON PARKWAYTELEPHONE:
(949) 458-2311
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 305CENSUS: 91DATE:
06/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Melanie Sigar, Assistant Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Melanie Sigar, Assistant Executive Director and LPA explained the nature of the visit. Facility is licensed for 115 ambulatory, 174 non-ambulatory residents, of which 16 may be bedridden. Facility has an approved hospice waiver for 20 residents. The facility currently has 7 residents are on hospice during today's visit.

LPA Martinez along with Assistant Executive Director toured the inside and outside of the physical plant of the facility. LPA observed a bistro on the first floor where residents can obtain different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus for both areas and the food offered is varied and healthful. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen. During the tour LPA observed residents involved in an activity as well as a posted activity schedule including games, exercise, and outings at the facility. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room. LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care. Facility has apartment style bedroom for residents. LPA inspected apartments; all required components were observed in inspected apartments. Each apartment has their own bathroom, LPA inspected resident bathrooms. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Various resident bathrooms were

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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 AT WELLINGTON, THE
FACILITY NUMBER: 306006222
VISIT DATE: 06/18/2025
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tested for hot water temperature and water temperature measured between 117.6-120 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA observed the restrooms are equipped with a call button. Call button when pulled calls to caregiver pager as well as the front desk for response accuracy. LPA observe caregiver receive a call button notification and observed caregiver response to call. LPA observed several residents throughout the facility who appeared clean, and happy. LPA observed several courtyards with shaded seating areas for residents’ enjoyment. LPA observed a swimming pool with a fence around it. LPA observed the pool gate has five self-latching entry door which opens towards the pool. The fence has a key lock at the gate door for inaccessibility. LPA measured the pool fence which measured 6.08 ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPA observed the pool has five entry doors throughout the pool area. Toxic chemicals, cleaning solutions and disinfectants are stored locked in the housekeeping storage closet. Carbon monoxide detectors tested and noted to be operational. LPA observed fire extinguishers throughout the facility that are fully charged and had a service date of March 17, 2025. LPA verified fire drills are conducted and logs reflect the last fire drill conducted was May 19, 2025. Fire drills are conducted quarterly. Smoke detectors and sprinkler system are tested by an outside agency. LPA verified the last sprinkler inspection was conducted June 17, 2025 and they are done quarterly. Smoke detectors are inspected every 6 months and last inspection was June 10, 2025. LPA verified all systems passed inspection. Facility has ten stairwells and ten evacuation chairs in those stairwells. LPA began the review of records. LPA reviewed nine resident files, all resident files contained required documentation including updated physician reports and care plans. LPA reviewed five staff files. Staff files contained required documentation including health screens, first aid, and fingerprint clearance.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.



This report was reviewed with the facility representative and a copy of this report was provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Ruth Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC809 (FAS) - (06/04)
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