306006435-7-18-2024-22-AS-JCHO-D7ANQG-20240718103955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006435
Report Date: 07/18/2024
Date Signed: 07/18/2024 10:40:06 AM

Document Has Been Signed on 07/18/2024 10:40 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IVY PARK AT TUSTIN		FACILITY NUMBER:	306006435
ADMINISTRATOR:	BROADHURST, BRENT		FACILITY TYPE:	740
ADDRESS:	12291 S. NEWPORT AVE.		TELEPHONE:	(714) 544-5959
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	70	CENSUS: 47	DATE:	07/18/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	07:00 AM
MET WITH:	Sandra Acosta-Louer- Executive Director		TIME COMPLETED:	11:00 AM

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) Jessica Cho arrived at the facility announced for the purpose of conducting a Pre-Licensing visit for a change of ownership. LPA conducted the visit with Executive Director (ED) Sandra Acosta-Louer. An initial application to operate a Residential Facility for the Elderly was received by the Department of Social Services on September 26, 2023, for a capacity of 70 residents with today's census at 47. LPA toured the initial and exterior of the facility and observed the following accompanied by the ED: Structure: Facility is a single story commercial building comprised of a total of 53 apartments, 38 in the Assisted Living (AL) and 15 apartments in the Memory Care (MC) unit with each apartment having its own bathroom. LPA observed all common areas and public bathrooms. There is a courtyard with a patio cover designated for the AL and MC and two egress doors in the MC area. Signal System: The facility does have a signal system where staff are alerted through their company issued cell phones. Bedrooms: The resident bedrooms had all required components, are spacious, and easily accommodates the residents’ furnishings. Bathrooms: Bathrooms were clean and operational. Grab bars were secure. The water temperature for five resident bathrooms measured between the ranges of 116.7 and 123.4 degrees Fahrenheit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK AT TUSTIN	FACILITY NUMBER: 306006435
	VISIT DATE: 07/18/2024

NARRATIVE

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Linens and Hygiene Supplies:
Clean linens were observed to be fully stocked.

Appliances:
Stove burners, microwaves, washers, and dryers were inspected.

Emergency Phone Numbers/Exit Plan:
Posted in the entry area of the facility and readily available for review.

Postings:
The Complaint Poster (PUB475) and the Long Term Care Ombudsman poster were posted in the entry area of the facility and in the memory care unit along with the Residents' Rights, Theft & Loss Policy, Monthly Newsletter, and the Activity Schedule. Facility did not post a copy of the admission agreement, meeting notes, and licensing reports or notice of their availability for the public to view.

Food Service and Menu:
Supply of seven day non-perishable and two day perishables were observed. The sample menu was available for review. The emergency food/water supply was stored in the closet expiring in 2031.

Smoke and Carbon Monoxide Detectors:
Smoke detector and carbon monoxide alert systems were tested and found to be operational per the inspection report conducted on April 30, 2024 by Johnson Controls.

Fire Extinguishers:
Fire extinguishers were mounted in an enclosed case, fully charged, and serviced on January 10, 2024. One extinguisher is in the company vehicle.

Fire Clearance:
Approved on October 30, 2023 for 62 non-ambulatory and 8 bedridden residents.
Toxins and Sharps:
Cleaning supplies, toxins, and sharps were secured.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY PARK AT TUSTIN	FACILITY NUMBER: 306006435
	VISIT DATE: 07/18/2024

NARRATIVE

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Water Temperature:
Five resident bathrooms tested. Two bathrooms were out of range, room #44 at 123.4 and room #45 at 122.9 degrees Fahrenheit.

Medications, First Aid Kit & Manual:
The facility had First Aid Kits which were checked and found to be in order. The First Aid kit is located in medication room and the company vehicle. The facility maintains the 2024 First Aid manual.

Client and Staff Files:

Client and staff records are maintained on site.

Reading Material, Games, Equipment, & Materials:
The facility had reading material and games present in the facility that commensurate with their plan of operation.

Component III:
Component III is waived due to the applicant having other licensed facilities and completing Component III previously.

The following items need correction prior to licensure:

Please ensure the water temperature in the resident bathrooms are within the range of 105-120 degrees Fahrenheit.
Please post a copy of the admission agreement, licensing report(s), and resident council meeting notes or maintain a notice of their availability for the public upon request.
Please complete and post Page 2 of the Emergency Disaster Plan (LIC610E) (3/19) that was missing.
Please hang the Administrator's Certificate.

Facility does not appear ready for licensure. Any items noted above during today’s visit are to be corrected by Tuesday, July 23, 2024 at 7:00am.

An exit interview was conducted with Executive Director Sandra Acosta-Louer, and a copy of this report was provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

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