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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006222
Report Date: 01/09/2025
Date Signed: 01/16/2025 09:26:17 AM

Document Has Been Signed on 01/16/2025 09:26 AM - 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/
DIRECTOR:		VADNAIS, GERRYFACILITY TYPE:
740
ADDRESS:24903 MOULTON PARKWAYTELEPHONE:
(949) 458-2311
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 305CENSUS: 117DATE:
01/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:46 PM
MET WITH:Marites Meneses- Health Services Director TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) made an unannounced visit for a case management in conjuction with complaint control 22-AS-20250102131745.

It was alleged that Resident 1 (R1) was administered unauthorized medications.

Per review of R1's medical records the facility received a fax from R1's current physician requesting the medication of Oxybutynin to be tapered off and then discontinued, the fax was received on 07/19/2023. Per review of medication administration records (MAR) Oxybutynin was tapered off and eventually discontinued in August of 2023, review of December 2023 MAR the medication is refilled by R1's former physician and continued to be given to R1 until August 14th 2024.

Based on interview with Health Services Director Marties Meneses she started at the community around August 2023. Health Services Director stated the order was followed but in December 2023, someone on her staff found the original order of Oxybutynin from R1's former physician dated 3/16/2023. Heath Services Director stated that once it was brought to her attention that an order was received on 07/19/2023 by R1's current physician then the MAR was updated. Health Services Director stated the order from 07/19/2023 was filed by previous Health Services Director and was not located until August 2024. Per interview with Health Services Director the issue was not reported to the Department.

Therefore based on interviews and records reviewed the following is being cited per Title 22.

An exit interview was conducted and a copy was provided to facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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Document Has Been Signed on 01/16/2025 09:26 AM - It Cannot Be Edited


Created By: Andrea Mendivil On 01/09/2025 at 04:16 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 AT WELLINGTON, THE
FACILITY NUMBER: 306006222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2025
Section Cited
CCR
87211(a)(D)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(D) Any incident which threatens the welfare, safety or health of any resident...
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Health Services Director to review regulation and provide proof to LPA by POC due date.
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This requirement was not met as evidence by facility did not report medication issue to the Department. This poses a potential safety risks to persons in care.
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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