306006223-10-22-2025-22-AS-APAO-DMRU3X-20251024151415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006223
Report Date: 10/22/2025
Date Signed: 10/22/2025 12:01:31 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
05/06/2024 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240506152040

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: 166	DATE:	10/22/2025
		UNANNOUNCED	TIME BEGAN:	07:20 AM
MET WITH:	Zehra Syed		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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-Facility threatened to evict resident
-Facility did not allow resident to reject medical care or other services
-Facility is not providing Basic Services to resident
-Facility coerced resident into accepting medication management

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrive at facility was greeted and granted entry. LPA spoke with Zehra Syed, Executive Director and explained the purpose of the visit.

Findings are based upon this investigation which included resident file review, facility file review, tour of the physical plant of the facility and interviews conducted.

It is alleged facility threatened to evict resident, specifically to receiving a letter signed and dated letter declaring that resident will either face eviction or agree to the services and charges. LPA Martinez requested a copy of the letter however such letter was never made available. LPA is unsure if the letter exist. Interview

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025

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-20240506152040

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: 10/22/2025

NARRATIVE

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with staff stated that an eviction was never given, however it was suggested if resident was unhappy with the services and care of the facility that they could move out at their leisure without penalty. Resident (R1) had been having changes in condition and temporary admittance to a skilled nursing facility and required change in services.

It is alleged that facility did not allow resident to reject medical care of other services. Record review revealed that R1 moved into the facility February 18, 2022 and after a few incidents and a short stay at a skilled nursing facility on April 8, 2024 R1 had a re-assessment. Resident appraisal dated February 16, 2022, reflected that resident required minimal services, due to R1 being independent. Assessment dated April 8, 2024, reflected that there was a change in the following areas personal care services for dressing, transfers, bathing, toileting needs, medication assistance, and fall risk. Per Tittle 22 regulations it the responsibility of a licensed facility to provide Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. "Care and Supervision" shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents.

It is alleged that facility is not providing basic services to resident. Interview with 3 of 3 staff stated that services were provided to resident despite of the disagreement with R1’s responsible party. Staff providing basic services to R1 is the reason staff identified that resident may have had a change of condition, and staff acted accordingly. R1 had a serious of events that led to going to the hospital and then later transferred to a skilled nursing facility. Staff would check on R1 often and would notice changes in the residents living environment.

It is alleged that facility coerced resident into accepting medication management. Interview with 3 of 3 staff stated that when resident initially moved in the facility, they were able to manage their own medication, R1 moved in February 18, 2022. Staff when providing services noted that there would be medication spilled on the floor and on R1’s bed. Therefore staff did the necessary for the noted change in condition and obtained new assessments to place resident on medication management if required. Record review revealed that due

Continued on LIC9099-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240506152040

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: 10/22/2025

NARRATIVE

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to a noted change in condition R1’s LIC602 Physicians report was updated on April 11 and 16, 2024, which noted on page 4 number 16 that R1 needed medication management and resident was unable to administer their own medication. R1’s responsible party upon disagreement had a new LIC602 Physicians report dated May 4, 2024, page 4 number 16 as yes able to manage own medication but to see section 19. Section 19 states R1 needs medication management that would be provided by patient’s son.

Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated.

An exit interview was conducted with Executive Director and a copy of this LIC9099 report was left at facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025

LIC9099 (FAS) - (06/04)

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