306006223-7-6-2023-22-AS-RMAZ-CTGSJF-20230706135504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006223
Report Date: 07/06/2023
Date Signed: 07/06/2023 01:55:14 PM

Document Has Been Signed on 07/06/2023 01:55 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IVY PARK AT LAGUNA WOODS		FACILITY NUMBER:	306006223
ADMINISTRATOR:	MADSEN, ELENA		FACILITY TYPE:	740
ADDRESS:	24441 CALLE SONORA		TELEPHONE:	(949) 830-8057
CITY:	LAGUNA WOODS	STATE: CA	ZIP CODE:	92637
CAPACITY:	233	CENSUS: 121	DATE:	07/06/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Elena Madsen		TIME COMPLETED:	02:30 PM

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	Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted and granted entry. LPA met with Elena Madsen, Executive Director/Administrator and discussed the visit. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (233) capacity, (75) ambulatory, (150) non-ambulatory, and (8) bedridden resident was submitted to CCL on August 01, 2022. Structure: The facility is a three-story building with 186 resident apartment style bedrooms, first floor common spaces are: kitchen, dining room, bistro, bar, library, med room, pavilion, and six common restrooms. Second floor common spaces are: therapy room and fitness center. Third floor common spaces: art room. There are 11 laundry units all together throughout all three floors. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There are two courtyards one by the main entry of the pavilion and another courtyard with a gated pool and a putting green area behind the pavilion, there is several seating areas for resident throughout both courtyards. There is a patio with seating for residents in front of the dining room/bistro. Signal system: Each apartment has a call button/pull cord to request assistance and residents also utilize pendant alert system to request assistance. CONTINUED ON LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK AT LAGUNA WOODS	FACILITY NUMBER: 306006223
	VISIT DATE: 07/06/2023

NARRATIVE

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Air/Heating:
Central air/heating system installed with a central panel to control entire building.

Bedrooms Residents:
Bedrooms are apartment style that will be private or shared.

Bedrooms Staff:
There is no live in staff and there is a designated staff lounge.

Bathrooms:
All bathrooms have a working toilet, wash basin, walk in shower/tub. There are six common restrooms on the first floor of the building and each apartment has its own bathroom.

Linens & Hygiene Supplies:
Facility has an adequate supply of linens in storage unit.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week.

Food Service:
Adequate supply of seven day non-perishable and two day perishables are stored in the kitchen with surplus good stored in storage room located on the second floor.

Smoke Detectors:
Smoke detectors, sprinklers and carbon monoxide alert systems are tested and maintained by an outside vendor. Fire extinguishers mounted throughout the facility charged with a date of December 19, 2022.

CONTINUED ON LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK AT LAGUNA WOODS	FACILITY NUMBER: 306006223
	VISIT DATE: 07/06/2023

NARRATIVE

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Appliances:
Residents’ apartments have small kitchen, electric stove, refrigerator, microwave, and small sink. Facility main kitchen on the firstfloor is equipped with ovens/ranges/microwaves, prep counters, refrigeration, freezer, grill, steam tables, there are washer and dryers in each of the 11 laundry units and all appliances are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored in housekeeping storage units.

Water Temperature:
Tested and recorded the water temperature measures 113.1 – 116.7 Fahrenheit degrees in all resident apartments and common bathrooms in floors one to three of the facility.

Pool:
Gated pool located on the first floor behind the pavilion and residents always have access to the pool with a staff member present.

Medications, First-Aid Kit & Book:
Medication, first aid and book are stored in med room inaccessible to residents. First aid kits are also located in med carts and throughout the facility in common spaces.

Resident & Staff Files
Records will be kept stored in a storage unit located on the third floor by apartment 310.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation.

CONTINUED ON LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK AT LAGUNA WOODS	FACILITY NUMBER: 306006223
	VISIT DATE: 07/06/2023

NARRATIVE

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Fire clearance:
Was approved on April 04, 2023. Non-ambulatory and bedridden residents only allowed on first and second floor.

Component III:
Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

Facility appears to be ready for licensure in the areas inspected. Accordingly, LPA will submit file for approval to CCL Supervisor. Exit interview was conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

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