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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006402
Report Date: 09/04/2024
Date Signed: 09/11/2024 07:22:19 AM


Document Has Been Signed on 09/11/2024 07:22 AM - 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 AT SEAL BEACHFACILITY NUMBER:
306006402
ADMINISTRATOR:TURGEON, JENNIFERFACILITY TYPE:
740
ADDRESS:3850 AND 3840 LAMPSON AVETELEPHONE:
(562) 594-5788
CITY:SEAL BEACHSTATE: CAZIP CODE:
90740
CAPACITY:261CENSUS: 170DATE:
09/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Executive Director, Tami OjwangTIME COMPLETED:
03:40 PM
NARRATIVE
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An unannounced case management visit was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding an incident report received by Community Care Licensing on July 30, 2024. LPA met with Executive Director (ED) Tami Ojwang and explained the purpose of the inspection.

Per incident report, on July 25, 2024, Resident 1’s (R1’s) representative reported that Staff 1 (S1) text them a video and photographs of R1. Video depicted R1 engaged in a verbal altercation with Staff 2 (S2), whom had “previously been investigated” and “was counseled.” Photographs depicted S2 assisting R1 with changing clothes. S1 resigned their position on Jully 25, 2024, in the middle of their shift.

During case management visit on August 9, 2024, interviews were conducted with staff and R1.

During their interview, S1 confirmed they had taken the video of the verbal altercation between S2 and R1 and stated they provided the video and a written statement about the incident to former ED Jennifer Turgeon and Staff 3 (S3) on June 5, 2024. Per S1, they resigned their position during their shift on July 25, 2024 because the incident went unaddressed despite the video evidence.

During their interview, S3 confirmed they were first notified of the incident and about the video in June, but stated they did not recall the exact date. S3 stated they had not watched the video and stated they did not have S1’s written statement as it had been provided to ED Turgeon.

During their interview, former ED Turgeon refused to provide LPA with S1’s written statement and provided LPA with their own written and signed statement, which stated an investigation had been completed on June 19, 2024, regarding S1’s report about S2 arguing with R1. Per ED’s written statement, S2 was asked about the incident and confirmed they had yelled at R1 and called them a “thief”. Former ED Turgeon stated S2 is no longer working with R1, but continues working at the facility in another area. (Cont. LIC9099-C)

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
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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Document Has Been Signed on 09/11/2024 07:22 AM - It Cannot Be Edited

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 AT SEAL BEACH
FACILITY NUMBER: 306006402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2024
Section Cited
CCR
87211(a)

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(1) a written report shall be submitted to the licensing agency.., within seven days of the occurrence of... (D) Any incident which threatens the welfare, safety or health of any resident...

This requirement is not met as evidence by:
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ED Ojwang stated they will provide LPA with a written plan of action to ensure compliance with regulation via email by POC date.
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Based on observations and AD admission, the Licensee did not comply with the section cited above, as incident was not reported to CCL for over 30 days, which posed an immediate personal rights risk to persons in care.
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Type A
09/05/2024
Section Cited
CCR87468.1(a)

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(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

This requirement is not met as evidence by:
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Per ED, S2 will no longer be working with R1. ED stated staff training will be conducted regarding residents' personal rights and proof submitted to LPA via email by POC date.
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Based on video evidence and staff interviews, the Licensee did not comply with the section cited above as S2 yelled at R1 and calling them a "thief" which poses an immediate safety and personal rights risk to persons 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.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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 AT SEAL BEACH
FACILITY NUMBER: 306006402
VISIT DATE: 09/04/2024
NARRATIVE
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An incident report was not submitted to CCL regarding the video, S1’s written statement, and/or “investigation” conducted by ED until July 30, 2024.

Based on observations, deficiencies are being cited per Title 22, Division 6 of the California Code of regulations. An exit interview was conducted a copy of this report was provided at the end of the inspection.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3