306006233-9-26-2023-22-AS-SHAD-CW2RVS-20230926132201

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006233
Report Date: 09/26/2023
Date Signed: 09/26/2023 01:22:08 PM

Document Has Been Signed on 09/26/2023 01:22 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IVY PARK OF WELLINGTON		FACILITY NUMBER:	306006233
ADMINISTRATOR:	CASTILO, MONICA		FACILITY TYPE:	740
ADDRESS:	24962 CALLE ARAGON		TELEPHONE:	(562) 865-9500
CITY:	LAGUNA WOODS	STATE: CA	ZIP CODE:	92637
CAPACITY:	220	CENSUS: 161	DATE:	09/26/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Monica Castilo		TIME COMPLETED:	01:35 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) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Applicant (AP) Monica Castilo, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 08/01/2022. This is a change of ownership with persons in care. During the inspection, LPA and AP observed the following: Structure: facility is a large commercial facility. There is one building with four stories. The memory care unit is on the first floor with delayed egress and has its own common areas, dining room, and two outdoor patios. The rest of the building is for assisted living. The assisted living kitchen and dining room are on the second floor. There are two outdoor courtyards for assisted living residents on the first floor. There is a dedicated medication room for the memory care unit and also one for the assisted living section. There are 21 bedrooms in the memory care unit and 155 bedrooms in the assisted living section, with each bedroom having its own bathroom. There are also common bathrooms, activity rooms, and common areas throughout the facility. Facility telephone number is (949) 586-3393. Resident Bedrooms: the resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lights, chairs, linens, and storage for 12 resident bedrooms inspected. Bathrooms: were clean, faucets and toilets were operational. Water temperature: tested between 114 degrees F and 118.9 degrees between the 12 resident bathroom faucets tested. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: 2 days perishable and 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the first floor housekeeping room. Medications are locked in medication carts inside the two medication rooms. First-Aid Kit & Activity Supplies: observed and available.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK OF WELLINGTON	FACILITY NUMBER: 306006233
	VISIT DATE: 09/26/2023

NARRATIVE

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Resident & Staff Files: LPA reviewed 5 resident files and 5 staff files. Fire clearance was approved by Orange County Fire Authority on 07/02/2023. Courtyard exit gates are operational and unlocked. Courtyards have shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. Facility is currently operating under the liability insurance of current facility LAS PALMAS (306005349). AP will switch liability insurance to new facility once the application is approved.

During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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