<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006222
Report Date: 11/14/2025
Date Signed: 11/14/2025 03:18:51 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
01/29/2024 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240129065431
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: 123DATE:
11/14/2025
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Gerry Vadnais-Senior Executive DirectorTIME COMPLETED:
03:36 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not safeguard medications
Facility staff are not trained in medication administration
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on January 29, 2024. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Gerry Vadnais. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that facility did not safeguard medications. Regarding the allegation the following was revealed: During the course of the interviews with individuals nine of nine individuals interviewed denied the allegations. During the initial visit on February 8, 2024, and subsequent visits on October 29, 2025, and November 14, 2025, LPA tour the facility and observed that the medications were locked inside the Medication Room. LPA also observed that the Medication Technicians (MTs) need a key to open the Medication carts. During the course of the interviews with residents, Resident 2 (R2) reported that the facility staff safeguard the medications properly. Per R3, she manages her own medications and stated that the medications get stored and locked in the Medication room.
CONTINUED ON LIC9099-C...
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
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-20240129065431
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 AT WELLINGTON, THE
FACILITY NUMBER: 306006222
VISIT DATE: 11/14/2025
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
26
27
28
29
30
31
32
R4 stated that staff secure the medications properly. Per R5, staff manage her medications and reported that staff safeguard the medications properly. During the course of the interviews with staff, Staff 1 (S1) reported that staff properly safeguard the Medications in the Medication carts and stated that only the MTs have a key to lock the Medication cart. S2 stated that staff properly safeguard the residents' Medications. Per S3, staff always safeguard the Medications in the Medication room.

Regarding the allegation that facility staff are not trained in medication administration, the following was revealed: During the course of the investigation LPA reviewed documents including the Medication Technician Training Records dated April 13, 2023, for staff S1-S5. Per Medication Technician Training Record, S1-S5 completed 24 hours of initial training. Per Medication Technician Training Records S1-S5 completed 16 hours of hands-on shadowing training and eight hours of instructions/online training. During the course of the interviews with residents, R1 reported that staff are trained in medication administration. Per R2, staff are properly trained in medication administration. R4 stated that staff have completed all their trainings and reported that he is very happy with all staff. Per R5, staff are trained in Medication administration. During the course of the interviews with staff, S1 reported that the MTs have completed their trainings on administering Medications. Per S3, the MTs are trained in administering Medications and stated that the MTs do monthly Relias trainings and do monthly in-service trainings as needed. During the course of the interviews ED reported that staff are trained on Medication administration and stated that staff complete their trainings online or in-service trainings as needed.

Therefore, the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or are without a reasonable basis.

LPA Ramirez conducted an exit interview with ED and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
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
01/29/2024 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240129065431

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: 123DATE:
11/14/2025
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Gerry Vadnais-Senior Executive DirectorTIME COMPLETED:
03:36 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility allowing unskilled staff to perform injections
Facility staff falsifies documents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on January 29, 2024. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Gerry Vadnais. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that facility is allowing unskilled staff to perform injections. Regarding the allegation the following was revealed: During the course of the interviews with residents, R1 reported that she is not aware about staff performing injections on residents. Per R2, she is not aware about staff performing injections on the residents. R3 stated that she is not aware if staff are performing injections on the residents. Per R4, he is not aware about staff performing injections on the residents. R5 stated that she has no knowledge regarding staff performing injections on the residents. During the course of the interviews with staff, Staff 1 (S1) reported that staff do not assist the residents with injections.
CONTINUED ON LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
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-20240129065431
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 AT WELLINGTON, THE
FACILITY NUMBER: 306006222
VISIT DATE: 11/14/2025
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
26
27
28
29
30
31
32
Per S2, staff have never performed injections on the residents. S3 stated that staff have never performed injections on the residents. During the course of the interviews ED reported that staff are not allowed to perform injections since this is an Assisted Living. Per ED, the facility does not have the proper staff to perform injections.

Regarding the allegation that facility staff falsified documents, the following was revealed: During the course of the interviews with individuals eight of nine individuals interviewed denied the allegations. During the course of the interviews with residents, R1 reported that she doubts that staff have falsified documents and stated that she has no complaints. Per R2, staff do not falsify documents. R3 stated that she does not have knowledge about staff falsifying the residents records. Per R4, he does not know if staff have falsified documents. R5 reported that staff do not falsify documents. During the course of the interviews with staff, S1 reported that staff have never falsified facility records and stated that she has never witness staff being forced to falsify documents. Per S2, she heard that staff sign for missing Medications. S3 stated that staff have never falsified facility or resident records. Per S3, she has never forced staff to falsify the Medications documentation. During the course of the interviews ED reported that if staff falsify documents, staff would be written up or terminated.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED.

For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations.

LPA conducted an exit interview with ED Vadnais, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4