306006222-6-25-2024-22-AS-AORZ-D8ELA9-20240823083444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006222
Report Date: 06/25/2024
Date Signed: 06/25/2024 12:03:18 PM

Unsubstantiated

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
06/18/2024 and conducted by Evaluator Jenifer Tirre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240618142643

FACILITY NAME:	IVY AT WELLINGTON, THE		FACILITY NUMBER:	306006222
ADMINISTRATOR:	OLSON, KATHLEEN		FACILITY TYPE:	740
ADDRESS:	24903 MOULTON PARKWAY		TELEPHONE:	(949) 458-2311
CITY:	ALISO VIEJO	STATE: CA	ZIP CODE:	92653
CAPACITY:	305	CENSUS: 119	DATE:	06/25/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Gerry Vadnais-Senior Executive Director		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Staff are not following infection control requirements

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver findings on complaint investigation into the above allegations. LPA explained the reason for the visit with Senior Executive Director Gerry Vadnais.

During the course of the investigation LPA toured facility with Health Service Director, conducted interviews with staff and residents, made visual observations and requested pertinent documentation such as Resident Roster, staff roster, notification letter, incident reports and copy of essential precautions.
During investigation LPA conducted interviews with staff and residents. Staff interviews revealed that facility has infection control precautions put into place for Covid 19 such as masks available at reception desk & Health Services room for residents, Caregiving staff, Dining room staff & maintenance staff are required to wear masks when coming into contact with residents. Staff interviews also revealed that staff are cleaning surfaces daily in common areas such as dining room, cafe, activitiy rooms, fitness center and restrooms. CONTINUED ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240618142643

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: 06/25/2024

NARRATIVE

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Health Services Director states they have been in contact with Department of Public Health, resident families and contacted Licensing regarding covid positives. Staff interviews revealed that facility sends notification letter to residents and responsible parties inside on site mailboxes. Resident interviews revealed that half of residents interviewed confirmed they receive letters inside mailboxes while other half state they could not recall if they receive letters regarding Covid 19 notifications. All residents interviewed confirmed that staff are helpful regarding resident concerns.

During visit LPA observed facility has hand sanitizer stations in common areas such as lobby, dining room, activities area, fitness room, cafe area, inside elevators and restrooms on each floor. LPA observed caregiver, dining staff and maintenance staff wearing masks. LPA observed Personal Protective Equipment carts outside of Residents rooms and observed hand washing signs located inside common area restrooms. LPA observed cases of PPE supplies such as gloves, surgical masks, face shields, N-95 masks and sanitizer.

LPA reviewed facility notification letter sent out to residents & responsible parties stating that facility is taking steps for residents protection such as offering more hand sanitizer, staff wearing masks, surfaces being cleaned daily, offering in room dining and protocols for residents who have tested positive. LPA reviewed Facility essential precautions which state that residents, staff or visitors will be tested if covid symptoms are observed, routine sanitation of high touch surfaces daily, all suspected cases of covid will be retested 24 hours if symptom's occur. LPA also reviewed reporting requirements which state facility will report outbreaks. LPA observed Incident Reports which were provided by facility reporting cases.

Based on interviews conducted, observations made and records reviewed although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegation staff are not following infection control requirements is deemed UNSUBSTANTIATED.

An exit interview was conducted with Director and a copy of this report was reviewed and provided at the time of this visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC9099 (FAS) - (06/04)

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