306006223-7-10-2026-22-AS-JCHO-DVV2CM-20260710171658

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006223
Report Date: 07/10/2026
Date Signed: 07/10/2026 05:17:15 PM

Document Has Been Signed on 07/10/2026 05:17 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IVY PARK AT LAGUNA WOODS		FACILITY NUMBER:	306006223
ADMINISTRATOR/ DIRECTOR:	SYED, ZEHRA		FACILITY TYPE:	740
ADDRESS:	24441 CALLE SONORA		TELEPHONE:	(949) 830-8057
CITY:	LAGUNA WOODS	STATE: CA	ZIP CODE:	92637
CAPACITY: 233		CENSUS: 204	DATE:	07/10/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Zehra Syed- Executive Director		TIME VISIT/ INSPECTION COMPLETED:	05:15 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) Jessica Cho arrived unannounced for the purpose of conducting the Required 1 Year Inspection. LPA was greeted and granted entry by the receptionist after stating the reason for the visit. LPA was later greeted by Executive Director (ED) Zehra Syed. The facility is licensed for 233 residents of which 75 are ambulatory, 158 non-ambulatory, and 8 may be bedridden. Facility maintains a hospice waiver approved for 15. As of today’s date, the resident census is 204 of which 7 are receiving hospice care. Facility is operating within the conditions and limitations specified on the license. The ED has a valid administrator’s certificate expiring June 7, 2028. At or approximately 9:43am, LPA and Maintenance Director (MD) Jorge Aguirre toured the physical plant including all common areas. The facility is a three story property housing Assisted Living (AL) residents. LPA and MD observed the facility to be clean, sanitary, and in good repair. Hallways were free of clutter. LPA inspected a sample size of 10 resident units, however one resident refused the inspection for a personal reason. The resident bedrooms had all required elements with ample lighting. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, and the grab bars were secure. Showers were free of mold/mildew, and slip resistant mats were available. The hot water temperature in the resident bathrooms measured within range between 107.4-111.9 degrees Fahrenheit. LPA observed medications unsecured and accessible to residents in two units who are not authorized to manage their own medications per review of the Physician's Report (LIC602). All shared bathrooms in the common areas had sufficient supply of soap, toilet paper, and paper towels. LPA and MD inspected the kitchen and dining area. Facility maintains ample supply of two day perishables and seven day supply of non-perishable food.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK AT LAGUNA WOODS	FACILITY NUMBER: 306006223
	VISIT DATE: 07/10/2026

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LPA and MD observed staff engaged in food preparation wearing gloves and adhering to food sanitation practices. LPA observed medications are centrally stored in the medication room/carts with the exception of two resident units. Medications were administered as prescribed per review of the medications and Medication Administration Records (MARs). Toxins, chemicals, cleaning solutions are stored in a locked closet. The Complaint Poster (PUB 475) meets the size requirement and was posted in the entry way.

LPA and MD toured the outside grounds. The outdoor passageway is free of obstruction and slip hazards, and there are sufficient seating and shading. The swimming pool and exit gates are secured for the safety of the residents. Facility maintains two portable generators, emergency food supply, and (6) 200 gallon water containers. The fire extinguishers are mounted, charged, and serviced monthly per inspection tags noted June 15, 2026. The carbon monoxide detectors were available on levels 1 and 3 and tested operational. Per the fire alarm report, the smoke/carbon monoxide was tested on June 6, 2026. LPA and MD tested the dual functioning smoke/carbon monoxide detectors in 9 of 10 units. No issues found. The evacuation chairs were observed in each stairwell. Facility staff conducts monthly emergency disaster training which was last completed on June 11, 2026.

During inspection, LPA reviewed the Emergency Disaster Plan (LIC610E) and Provider Information Notice (PIN) Summary 25-06-ASC pertaining to Calling 9-1-1 in Residential Care Facilities for the Elderly (RCFE) . LPA conducted a review of 11 residents' and 3 staff files. No discrepancies noted. The medications and Medication Administration Records (MARs) were reviewed for 5 residents. No discrepancies noted. LPA also interviewed 6 residents today. The ED was reminded of the importance of ensuring medications are secured and inaccessible to residents who are not authorized to have access, store, administer own medications per doctor's order, to call 9-1-1 timely per PIN 25-06-ASC, and to update the Emergency Disaster Plan annually per feedback.

Based on the observations made, no deficiencies are being cited. However, a deficiency will be cited regarding the medications in connection to complaint control number: 22-AS-20260708102400. Advisory Notes (LIC9102s) are being issued during today's visit.

An exit interview was conducted with Executive Director Zehra Syed, and a copy of this report was provided at the end of the visit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026

LIC809 (FAS) - (06/04)

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