306006233-2-12-2024-22-AS-DLMN-D2E27G-20240212160842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006233
Report Date: 02/12/2024
Date Signed: 02/12/2024 04:09:26 PM

Document Has Been Signed on 02/12/2024 04:09 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IVY PARK OF WELLINGTON		FACILITY NUMBER:	306006233
ADMINISTRATOR:	CRAWFORD, ARLENE		FACILITY TYPE:	740
ADDRESS:	24962 CALLE ARAGON		TELEPHONE:	(562) 865-9500
CITY:	LAGUNA WOODS	STATE: CA	ZIP CODE:	92637
CAPACITY:	220	CENSUS: 150	DATE:	02/12/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Kathleen Olson - Interim Executive Director		TIME COMPLETED:	04:25 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) Dwayne Mason Jr. arrived at the facility to conduct and unannounced Case Management Incident Follow Up. LPA entered the facility and was greeted by Robin Colton in Reception. LPA stated the purpose of the inspection. Colton brought LPA to Interim Executive Director (IED) Kathleen Olson's office. LPA stated they are following up on the Unusual Incident Reports submitted to CCL on 1/24/24 regarding both spouses in a married couple. LPA obtained copies of the Admission Agreements, Resident Information Form and Resident Ledger pertaining to the couple. IED also provided LPA with a written list indicating each day the couple visited the facility for a meal. IED pulled these dates from Dining Room Meal Logs. LPA also obtained from the facility staff the Case Number, Detective name and Police station associated with the incident. Additionally, LPA obtained a photo of the Coroner's Seal affixed to the couple's private residence. Based on Record Review LPA determined the couple had been paying to rent a room at the facility since August 31, 2023. Based on interview with the IED, the residents paid to rent the room, visited the facility but resided at a private residence away from the facility. LPA conducted a health and safety check and noted two panels missing from the ceiling tiles. IED stated the removed tiles sustained water damage during recent rain and were removed so they could dry. IED stated service has been scheduled to repair ceiling tiles. IED stated that when the couple moved in, they only moved in a few pieces of furniture and stated they would not be residing in the room and did not want to receive service. LPA toured the couple's room and noted a bed in each room, two wooden chairs in the living room and a wooden table in the living room. LPA observed no personal items, food or entertainment devices in the facility apartment. LPA obtained photos of the room. (Continued on LIC809C)

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

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

FACILITY NAME: IVY PARK OF WELLINGTON	FACILITY NUMBER: 306006233
	VISIT DATE: 02/12/2024

NARRATIVE

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Based on Record review, the couple came to the facility 21 times for meals in September, 14 times for meals in October, 5 times in November and 1 day in December. The couple was last at the facility on December 4, 2023 for a meal. On December 18, 2023 Jessica Bacca, Senior Sales Manager, began calling the couple to find out their whereabouts. After being unable to get a hold of the couple via phone, the facility began calling the emergency contact listed on the Resident Information Form for the couple. The facility was unable to get a hold of the emergency contact. Iberia Tarin, Business Office Director called the couple on January 3, 2024 following a declined payment. LPA verified via Record Review the facility froze the couple's account on January 4, 2024. On January 16, 2024, Bacca conducted a wellness check at the couple's private residence due to concerns surrounding their well being. Upon arrival, Bacca observed and photographed the Coroner's seal affixed to the door of the couple's private residence.

Licensing Program Analyst conducted an exit interview with Interim Executive Director Kathleen Olson and a copy of this report was provided.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC809 (FAS) - (06/04)

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