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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006233
Report Date: 09/04/2026
Date Signed: 09/04/2026 02:58:59 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/04/2026 02:58 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 OF WELLINGTONFACILITY NUMBER:
306006233
ADMINISTRATOR/
DIRECTOR:		LAURA KEPHARTFACILITY TYPE:
740
ADDRESS:24962 CALLE ARAGONTELEPHONE:
(949) 586-3393
CITY:LAGUNA WOODSSTATE: CAZIP CODE:
92637
CAPACITY: 220CENSUS: 151DATE:
09/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Laura KephartTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director (ED) Laura Kephart and explained the reason for the visit. The ED's Administrator's Certificate expires on April 6, 2027. The facility is a four story building which has a memory care on the first level with approved secured perimeter and delayed egress exits. There are 2 courtyards, one courtyard has a pool with a secured fence. Both courtyards have shaded areas with tables and chairs to sit outside. Facility has a capacity of 220, 92 ambulatory, 120 non-ambulatory and 8 bedridden with a hospice waiver for 25. At this time 4 residents are on hospice. LPA and the ED toured the facility.
LPA observed the common areas such as the main lobby sitting area, activity room, gym room, movie theater, library, dining room and private meeting rooms were free of obstacles and hazards. LPA observed the See Something Say Something sign (PUB 475) from the main entrance of the facility. The first floor is memory care and has a secured perimeter. LPA tested the delayed egress doors in memory care and all the doors are operational. LPA toured the kitchen. LPA observed the kitchen is clean and organized. LPA observed a two day perishable and a 7 day non-perishable food supply on hand in the kitchen. The facility has a 3 day emergency supply of food and water stored in a storage room. LPA observed the refrigerator and freezer were at the required temperatures. LPA observed all cleaning supplies are kept locked in storage closets throughout the facility. LPA inspected resident rooms on each floor of the facility. LPA observed all resident rooms had the required furnishings and bed linens. Hot water in the rooms inspected measured 112.8 to 115.3 degrees Fahrenheit. All resident rooms inspected were clean and ample storage space. LPA observed all fire extinguishers throughout the facility are fully charged. The last emergency drill was conducted on June 16, 2026. LPA observed the facility has a internet device (computer) for resident use only. LPA observed each stairway has an emergency evacuation chair. LPA toured both courtyards. No obstacles or hazards observed. The pool has a gated fence and the gate is kept locked.
Sheila Santos
Joseph Alejandre
DATE: 09/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2026
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 OF WELLINGTON
FACILITY NUMBER: 306006233
VISIT DATE: 09/04/2026
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LPA observed medications are kept locked in the medication room. LPA inspected the first aid kit. The first aid kit has all the required elements. LPA reviewed 15 staff files and reviewed 5 resident medications. No discrepancies observed. LPA reviewed 5 staff files (caregivers). LPA observed that 5 out of 5 staff have over 20 hours of training including 8 hours of Dementia training. LPA observed that 4 out of 5 staff members (caregivers, Staff 1, Staff 2, Staff 3, Staff 4) did not have 4 hours of training on postural supports, restricted health conditions, and hospice care. No other discrepancies observed. LPA observed all med-techs on duty had current CPR/Training. All staff members whose files were reviewed are background cleared and associated to the facility. All staff members that the LPA spoke to during the visit are background cleared and associated to the facility. No obstacle or hazards observed inside or outside of the facility. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2026 02:58 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 09/04/2026 at 02:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK OF WELLINGTON
FACILITY NUMBER: 306006233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
HSC
1569.625(b)(2)

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training requirements shall also include an additional 20 hours annually... and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696.
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Licensee agrees to train staff in compliance with HSC 1569.625, ensuring all caregiving staff are trained on 4 hours specific to postural supports, restricted health conditions and hospice care, including Staff 1, Staff 2, Staff 3 and Staff 4. Facility to submit proof of correction to LPA by POC due date
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This requirement is not being met as evidenced by LPA observed 4 out 5 staff files (Staff 1 through 4) reviewed did not have four hours of training specific to postural supports, restricted health conditions and hospice care which poses a potential health and safety risk to residents 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.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2026


LIC809 (FAS) - (06/04)
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