306006402-8-11-2025-22-AS-AORZ-DKRTBU-20250821143543

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006402
Report Date: 08/11/2025
Date Signed: 08/11/2025 10:23:32 AM

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
06/09/2025 and conducted by Evaluator RoseMarie Ruppert

COMPLAINT CONTROL NUMBER: 22-AS-20250609111614

FACILITY NAME:	IVY PARK AT SEAL BEACH		FACILITY NUMBER:	306006402
ADMINISTRATOR:	TAMI OJWANG		FACILITY TYPE:	740
ADDRESS:	3850 AND 3840 LAMPSON AVE		TELEPHONE:	(562) 594-5788
CITY:	SEAL BEACH	STATE: CA	ZIP CODE:	90740
CAPACITY:	261	CENSUS: 182	DATE:	08/11/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Tami Ojwang, Executive Director		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility staff did not address resident's fall risk
Facility staff did not address resident's change in condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit regarding a complaint received in our Regional Office. LPA was greeted and granted entry and explained the purpose of the visit. LPA met with Tami Ojwang, Executive Director.

LPA obtained and reviewed the following documents: Unusual Incident Reports for the past six months, Resident #1 (R1's) facesheet, Physician's Report, Preplacement Appraisal, Appraisal and Needs and Services Plan. LPA reviewed hospital discharge paperwork and Home Health Agency notes. LPA requested and reviewed facility notes regarding each of the fall incidents for R1.

R1 moved in July 25, 2024 and began to have falls on December 12, 2024, February 7, 2025, March 8, 2025, May 24, 2025 and June 4, 2025. Resident received Home Health (HH) services and LPA obtained
(Continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025

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 3

Control Number 22-AS-20250609111614

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 SEAL BEACH	FACILITY NUMBER: 306006402
	VISIT DATE: 08/11/2025

NARRATIVE

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(Continued from LIC 9099)

HH notes. Each of the dates were documented by HH, who provided wound care and mental assessment and worked with facility staff to prevent falls and to observe any changes in condition. Facility also documented on Unusual Incident Reports to the Department regarding R1's falls and the medical services received.

On June 16, 2025 LPA interviewed three of three residents regarding care received. Three of three residents did not have issues with care and that staff arrived in a timely manner and would check on them throughout the day. LPA toured R1's apartment and did not observe any immediate fall risks and spoke with Resident #2 (R2) who is R1's spouse, regarding any care issues. R2 stated everything was fine.

It is alleged the: Facility staff did not address resident's fall risk. LPA interviewed two of two staff members regarding Resident #1 (R1) and both felt staff constantly checked on R1 and Resident #2 (R2) due to R2's higher level of care. Staff reported R1 had access to a pendant at all times and had frequent checks. The Responsible Party (RP) was notified of R1's falls and does not have any concerns other than the resident has falls due to becoming weaker. Both the facility and Home Health continued to monitor R1's fall risk and were in communication with the RP.

It was alleged the Facility staff did not address resident's change in condition. Unusual Incident Reports and Home Health notes both documented that if R1 had any systemic infections; facility and home health were to follow-up with physician if any changes of condition were observed. Both facility and HH continued to monitor R1's falls and assess R1. Home Health notes on March 10, 2025 documented R1, who was initially independent, was no longer able to leave the community and that facility staff and RP were informed. Two of two staff reported R1 continued to have frequent checks and that R1 would not press pendant for assistance. On May 24, 2025 R1 was sent for further evaluation after a fall and returned to the community with no new orders. R1 fell on June 4, 2025 and was admitted at the hospital and Skilled Nursing for rehabilitation. R1 will return to the community on August 12, 2025.

Based on LPA record review and interviews, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the
(Continued on LIC 9099C1)

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20250609111614

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 SEAL BEACH	FACILITY NUMBER: 306006402
	VISIT DATE: 08/11/2025

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 26 27 28 29 30 31 32	(Continued from LIC 9099C) allegations that: Facility staff did not address resident's fall risk and Facility staff did not address resident's change in condition are Unsubstantiated. An exit interview was conducted with Executive Director Tami Ojwang and a copy of the report was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3