306006435-7-31-2026-22-AS-AMEL-DWHUUT-20260731155400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006435
Report Date: 07/31/2026
Date Signed: 07/31/2026 03:54:21 PM

Document Has Been Signed on 07/31/2026 03:54 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	IVY PARK AT TUSTIN		FACILITY NUMBER:	306006435
ADMINISTRATOR/ DIRECTOR:	LOUER, SANDRA ACOSTA		FACILITY TYPE:	740
ADDRESS:	12291 S. NEWPORT AVE.		TELEPHONE:	(714) 544-5959
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY: 70		CENSUS: 51	DATE:	07/31/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:59 AM
MET WITH:	Sandra Acosta Louer - Executive Director		TIME VISIT/ INSPECTION COMPLETED:	04:15 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	On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual. LPA was greeted and granted entry into the facility and explained the reason for the visit. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for seventy residents, of which seventy can be non-ambulatory, eight can be bedridden, and has a hospice waiver for fifteen. The facility is a one story commercial building comprised of fifty three apartments, forty two of which are on the assisted living side and eleven of which are in memory care. The facility also consist of common areas such as dining rooms in both the assisted living and memory care, activity areas, a commercial kitchen, and staff offices. LPA Mendivil and ED Sandra Acosta Louer conducted a tour of the interior portions of the facility. On today's visit, there are fifty one residents in care. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected seven resident bedrooms located throughout the facility and observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA tested the call buttons in resident bedroom and they tested operational. LPA inspected the resident bathrooms in the apartments inspected and observed them to be clean. LPA observed resident bathrooms to be equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 113.7 to 119.1 degrees Fahrenheit.

Alisa Ortiz
Andrea Mendivil
	DATE: 07/31/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

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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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 TUSTIN	FACILITY NUMBER: 306006435
	VISIT DATE: 07/31/2026

NARRATIVE

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LPA inspected the facility kitchen area and observed it be clean. LPA observed the facility to have a minimum two day perishable and seven day non-perishable food supply on hand. LPA observed the facility has a three day emergency food and water supply kept in a storage room. LPA observed multiple fire extinguishers to be mounted in the wall across the facility. LPA observed that the facility had their most recent Fire Inspection conducted on April 15, 2026. LPA observed that the facility fire sprinklers and smoke detectors tested operational during the inspection. LPA observed the facility conducted their last emergency disaster drill on June 11, 2026.

LPA, accompanied by the ED, conducted a tour of the exterior portions of the facility. LPA observed the facility has outdoor areas for both assisted living and memory care. LPA observed the exterior to be free of obstructions and hazards. LPA observed shaded outdoor seating areas with furniture for resident use.

LPA reviewed the seven resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed six staff files. All staff are background cleared and associated to the facility. Five out of six staff training records reviewed did not meet the requirements for four hours of training on hospice, postural supports and restricted health conditions.

Based on the observations made during today's visit, a deficiency is being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Executive Director Sandra Acosta Louer and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Andrea Mendivil
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

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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Document Has Been Signed on 07/31/2026 03:54 PM - It Cannot Be Edited

Created By: Andrea Mendivil On 07/31/2026 at 03:28 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 AT TUSTIN	FACILITY NUMBER: 306006435
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, 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. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed the Licensee did not comply with the cited above in five out of six staff training records reviewed did not meet the requirements for four hours of training on hospice, postural supports and restricted health conditions. This poses a potential health and safety risks to persons in care.
	POC Due Date: 08/13/2026
	Plan of Correction
1 2 3 4	Administrator stated will conduct in service training for postural supports, hospice and restriced health conditions to add the needed two additional hours.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:

	Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026

LIC809 (FAS) - (06/04)

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