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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006222
Report Date: 01/09/2025
Date Signed: 01/09/2025 04:38:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/02/2025 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20250102131745
FACILITY NAME:IVY AT WELLINGTON, THEFACILITY NUMBER:
306006222
ADMINISTRATOR:VADNAIS, GERRYFACILITY TYPE:
740
ADDRESS:24903 MOULTON PARKWAYTELEPHONE:
(949) 458-2311
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:305CENSUS: 117DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Marites Meneses- Healthcare Director TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility administered unauthorized medications
Facility staff did not provide medications as prescribed
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA Mendivil was greeted and granted entry into the facility by Executive Director Gerry Vadnais and explained the reason for the visit.

The Department received a complaint on 01/02/2025 and the initial 10 day visit was conducted on 01/09/2025. During the visit LPA Mendivil interviewed staff and obtained copies of medication administration records from July 2023 to December 2024, physician reports, and doctors orders. Regarding the allegations facility administered unauthorized medications and facility did not provide medications as prescribed, the investigation revealed the following:

It was alleged that Resident 1 (R1) was administered unauthorized medications.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20250102131745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/09/2025
NARRATIVE
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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.

It was alleged on or around December 2023 R1's neurologist prescribed Sertraline. Per interview with Health Services Director it was confirmed the facility received a prescription for Sertraline on 12/29/2023. Per review of the MAR Sertraline was not given to R1 until 2/10/2024. Health Services Director was unable to provide information as to why the medication was not provided from 12/29/2023 to 02/09/2024 as she stated it was added to medication list by pharmacy. LPA Mendivil's review of MAR from December 2023 to February 2024 do not mention Sertraline or any brand name for Sertraline until 2/10/2024.

Therefore based on the preponderance of evidence through records reviewed and interviews the allegations
facility did not provide medications as prescribed and facility did not meet reporting requirements are determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250102131745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2025
Section Cited
CCR
87465(e)
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(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication
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Health Services Director resolved issue with R1 by discontiuning medication based on current physician's orders. Health Services Director agreed to weekly audits of residents medications and MAR
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This requirement was not met as evidence by facility provided R1 with medication that was not authorized after being discontinued by current physician. This poses an immediate health and safety risks to persons in care.
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Type A
01/10/2025
Section Cited
CCR
87465(a)(4)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
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Health Services Director resolved issue with R1 by starting the medication as prescribed. Health Services Director has implemented an electronic system for prescription updates.
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4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by resident was not given prescription medications from 12/29/2023 to 02/09/2024.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3