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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006223
Report Date: 10/03/2025
Date Signed: 10/03/2025 03:44:28 PM

Substantiated


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
04/18/2025 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250418135127
FACILITY NAME:IVY PARK AT LAGUNA WOODSFACILITY NUMBER:
306006223
ADMINISTRATOR:TURGEON, JENNIFERFACILITY TYPE:
740
ADDRESS:24441 CALLE SONORATELEPHONE:
(949) 830-8057
CITY:LAGUNA WOODSSTATE: CAZIP CODE:
92637
CAPACITY:233CENSUS: 173DATE:
10/03/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jessica Hernandez, Business Office ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff stole a resident's personal property

Staff did not respond to residents calls for assistance timely
INVESTIGATION FINDINGS:
1
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5
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7
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10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the five allegations listed above and delivering findings to the licensee. LPA was greeted and granted entry by facility staff after stating the purpose of the visit. Business Office Manager Jessica Hernandez was present on the premises and presented with the allegations as well as the findings.

The initial investigation visit was conducted on April 21, 2025, by Licensing Program Analyst (LPA), Kevin Saborit-Guasch. During the visit, LPA accompanied by facility staff conducted a tour of the facility's three levels and common areas. No immediate risk to residents' health and safety was assessed. LPA requested and reviewed records for multiple residents.
Resident 1 (R1) was admitted to Ivy Park at Laguna Woods on December 2, 2023. Per the physician report established upon admission, R1 had a primary diagnosis of a history of lung and breast cancer.
CONTINUED ON FORM LIC9099
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
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 7
Control Number 22-AS-20250418135127
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 PARK AT LAGUNA WOODS
FACILITY NUMBER: 306006223
VISIT DATE: 10/03/2025
NARRATIVE
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CONTINUED FROM LIC9099
There is no indication of dementia or mild cognitive impairment on the medical assessment dated November 29, 2023. Upon admission, it was documented that R1 opted out of providing the facility with an inventory of personal property.

R1’s records obtained at the facility additionally included multiple Physician’s Fax Report of Fall dated January 4, 2024, February 13, 2024, June 11, 2024, January 13, 2025, March 5, 2025, March 6, 2025. In each of those instances, the primary care provider was notified and followed up. Adequate calls to 911 for evaluation and either transportation to a hospital or refusal to pursue such evaluation were systematically documented as well, as confirmed by the charting notes obtained and reviewed.

A Resident Notice to Vacate was provided by R1’s responsible party to the facility on April 5, 2025 informing the facility of R1’s intent to be discharged from the facility effective April 13, 2025. The motive stated on the notice is “multiple theft of cash and property, right wrist fracture due to employee negligence and involvement in a fall without proper response time”. R1 was therefore no longer a resident at the facility when the investigation was initiated.

Regarding the allegation that Staff stole residents personal property, the following has been concluded: During the investigation, licensing staff reviewed video footage from a video device installed by R1’s family inside unit #151. Video reviewed shows staff member S1 going into R1’s bedroom closet and removing items. S1 then comes into view of the camera and appears to back away out of view, before proceeding to walk by with items in hand. S1 is later seen leaving R1’s residential unit with items in hand. According to staff interviews, S1 instructed another staff member to tell her later in the shift, in the presence of other staff, to enjoy the items they gave them (even though staff did not give S1 anything). Accomplice staff agreed, later telling S1 that they hopes they enjoys the items and S1 thanked him for the gifts that he gave her. There is enough evidence to support the allegation that S1 stole items from R1’s residential unit.

CONTINUED ON FORM LIC9099-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 22-AS-20250418135127
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 PARK AT LAGUNA WOODS
FACILITY NUMBER: 306006223
VISIT DATE: 10/03/2025
NARRATIVE
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CONTINUED FROM LIC9099-C
Regarding the allegation that Staff did not respond to residents calls for assistance timely, it was determined that: During the investigation, licensing staff reviewed the Unusual Incident Report and interviewed the Med Tech that completed the report. Based on the report, R1 sustained a fall in the bathroom and pulled the emergency cord in the bathroom before crawling to their cell phone in the bedroom. R1 called their family who then called facility staff. R1’s family provided a time-stamped record of the calls confirming multiple phone calls to the facility were made. Once the call was received, the facility responded to provide aid/assistance. Both the report reviewed and a statement made by a staff member interviewed advised that the resident was not wearing her emergency pendant when staff responded.

Additionally, there was construction occurring at the facility in which the emergency cords in the bathroom were being removed. As a result, the facility staff stated they had thought the residents’ emergency cord notification was a false alarm due to the ongoing construction. There is enough evidence to support the allegation that there was a delay in providing assistance to R1 in a timely manner.

Based on the evidence gathered, the allegations that Staff stole residents personal property and that Staff did not respond to residents calls for assistance timely are both found to be Substantiated, meaning that the preponderance of evidence has been met.

See LIC9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
04/18/2025 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250418135127

FACILITY NAME:IVY PARK AT LAGUNA WOODSFACILITY NUMBER:
306006223
ADMINISTRATOR:TURGEON, JENNIFERFACILITY TYPE:
740
ADDRESS:24441 CALLE SONORATELEPHONE:
(949) 830-8057
CITY:LAGUNA WOODSSTATE: CAZIP CODE:
92637
CAPACITY:233CENSUS: DATE:
10/03/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Zehra Syed, Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek timely medical care for resident.

Staff financially abused resident.

Staff pushed resident causing injury.
INVESTIGATION FINDINGS:
1
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3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the five allegations listed above and delivering findings to the licensee. LPA was greeted and granted entry by facility staff after stating the purpose of the visit. Business Office Manager Jessica Hernandez was present on the premises and presented with the allegations as well as the findings.

The initial investigation visit was conducted on April 21, 2025, by Licensing Program Analyst (LPA), Kevin Saborit-Guasch. During the visit, LPA accompanied by facility staff conducted a tour of the facility's three levels and common areas. No immediate risk to residents' health and safety was assessed. LPA requested and reviewed records for multiple residents.
Resident 1 (R1) was admitted to Ivy Park at Laguna Woods on December 2, 2023. Per the physician report established upon admission, R1 had a primary diagnosis of a history of lung and breast cancer.
CONTINUED ON FORM LIC9099
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 22-AS-20250418135127
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 PARK AT LAGUNA WOODS
FACILITY NUMBER: 306006223
VISIT DATE: 10/03/2025
NARRATIVE
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CONTINUED FROM LIC9099-A
There is no indication of dementia or mild cognitive impairment on the medical assessment dated November 29, 2023. Upon admission, it was documented that R1 opted out of providing the facility with an inventory of personal property.

R1’s records obtained at the facility additionally included multiple Physician’s Fax Report of Fall dated January 4, 2024, February 13, 2024, June 11, 2024, January 13, 2025, March 5, 2025, March 6, 2025. In each of those instances, the primary care provider was notified and followed up. Adequate calls to 911 for evaluation and either transportation to a hospital or refusal to pursue such evaluation were systematically documented as well, as confirmed by the charting notes obtained and reviewed.
A Resident Notice to Vacate was provided by R1’s responsible party to the facility on April 5, 2025 informing the facility of R1’s intent to be discharged from the facility effective April 13, 2025. The motive stated on the notice is “multiple theft of cash and property, right wrist fracture due to employee negligence and involvement in a fall without proper response time”. R1 was therefore no longer a resident at the facility when the investigation was initiated.

Regarding the allegation that Staff did not seek timely medical care for resident, it was determined that: during the investigation, licensing staff reviewed the facility Charting Notes for R1 and also interviewed facility staff and R1’s family member. The Charting Notes document that R1 sustained an injury from a fall but also that R1 refused to accept treatment/transportation if 9-1-1 emergency personnel were called. R1 requested to be checked out for injury by a family member, who R1 stated is a doctor. Family member confirmed they are a physician and corroborated the account of refusal of medical treatment on the day of the fall incident. A few days later, R1 consented to hospital transportation. There is insufficient evidence to support the allegation of the facility failing to obtain medical attention.

Regarding the allegation that Staff financially abused resident, the following has been concluded: During the investigation, licensing staff conducted interviews with facility staff, clients, victim, and witnesses. The interviews conducted provided insufficient corroborating information regarding the allegation of staff stealing/removing money from R1’s possessions or bedroom. More importantly, the information provided did not allow to identify any individual staff that may have had direct involvement in the theft of cash. There is therefore insufficient evidence to support the allegation of staff stealing money from the resident.
CONTINUED ON FORM LIC9099-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20250418135127
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 PARK AT LAGUNA WOODS
FACILITY NUMBER: 306006223
VISIT DATE: 10/03/2025
NARRATIVE
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CONTINUED FROM FORM LIC9099-C
Regarding the allegation that Staff pushed resident causing injury, the following has been concluded: During the investigation, licensing staff conducted interviews with facility staff, clients, alleged victim, and witnesses. The interviews conducted provided insufficient corroborating information regarding the allegation of staff pushing or intentionally causing victim to fall. No specific alleged perpetrator was also identified based on the interviews. There is therefore insufficient evidence to support the allegation of staff intentionally pushing or causing the resident to sustain injury.

Based on the evidence gathered, the allegations that Staff did not seek timely medical care for resident, Staff financially abused resident and that Staff pushed resident causing injury are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20250418135127
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 PARK AT LAGUNA WOODS
FACILITY NUMBER: 306006223
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2025
Section Cited
CCR
87468.1(a)(2)
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Per CCR87468.1(a)(2) Personal Rights of Residents in All Facilities: "Residents (...) shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment." This requirement is not met as evidenced by:
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Staff member was terminated and is no longer associated to the facility. Licensee stated they would conduct an updated training regarding the theft and loss policy directed to care staff. Proof of training to be provided to the Department.
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Based on evidence reviewed, facility did not prevent S1 from stealing R1’s property while on duty at the facility. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.
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Type A
10/04/2025
Section Cited
CCR
878464(f)(1)
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Per CCR 878464(f)(1) on Basic Services: "Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c)". This requirement is not met as evidenced by:
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Licensee stated that all staff members would receive follow-up training on appropriate response to call system activations.
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Based on records reviewed and interviews conducted, excessive response time was corroborated in at least one instance after R1 sustained a fall. This constitutes an immediate risk to the health, safety and personal rights of individuals 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7