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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006222
Report Date: 07/26/2023
Date Signed: 07/26/2023 03:01:23 PM


Document Has Been Signed on 07/26/2023 03:01 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: 228DATE:
07/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Gerry Vadinais, Carri CollinsTIME COMPLETED:
03:15 PM
NARRATIVE
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This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following on a self-reported incident report received in the Orange County Regional Office (OCRO) on 07/24/23 regarding a medication error involving Resident #1 (R1). LPA met with Administrator (AD) Gerry Vadinais and Health Services Director (HSD) Carri Collins and discussed the purpose of the inspection.
The incident report states that on 07/17/23, R1 received twice the dose of Oxycodone. R1 was to receive one-half of a tab and instead received a full tab. When the medication error was noticed, facility staff conducted checks on R1 and noted no adverse reaction. Facility staff then checked on R1 every 2 hours for the next 72 hours. R1’s family and doctor were immediately notified. The Medication Technician who committed the error, Staff #1 (S1), was immediately pulled from dispensing medications and assigned to be fully retrained in medication management procedures. As of 07/21/23, R1 had no adverse reactions.

During today’s inspection, LPA interviewed HSD who provided the following information: the medication error was noticed approximately one and a half hours after administration during the re-count of medications; R1’s doctor advised that it was not necessary to send R1 to the hospital and it was OK for R1 to receive the full tab of Oxycodone as R1 had been previously prescribed a full tab but the prescription was changed to one-half of a tab upon R1’s request; and as of 07/26/23 R1 is doing fine.

During today’s inspection, LPA conducted a health and safety check on R1 and confirmed R1 was doing well and observed no health and safety issues. Per AD and HSD, S1 began the re-training process, but resigned after a few days. HSD stated that all Medication Technicians receive monthly training.

Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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Document Has Been Signed on 07/26/2023 03:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 306006222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2023
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee stated they will provide additional training to all Medication Technicians and submit proof to LPA by POC due date.
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Based on interview and documents, the licensee did not ensure R1 received assistance with self-administered medications due to a medication error, which posed a potential health and safety risk 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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