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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006451
Report Date: 08/01/2025
Date Signed: 08/01/2025 04:31:22 PM

Document Has Been Signed on 08/01/2025 04:31 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 AT LA PALMAFACILITY NUMBER:
306006451
ADMINISTRATOR/
DIRECTOR:		MUNOZ, JENNIFERFACILITY TYPE:
740
ADDRESS:5321 LA PALMA AVENUETELEPHONE:
7247398111
CITY:LA PALMASTATE: CAZIP CODE:
90623
CAPACITY: 80CENSUS: 70DATE:
08/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Executive Director, Jennifer MunozTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On August 1, 2025, Licensing Program Analyst’s (LPA’s) Jenifer Tirre and Eboni Bentley conducted an unannounced required visit using the CARE Inspection Tool. LPA’s were greeted by staff and granted entry after stating the purpose of the visit. Administrator (AD) Jennifer Munoz arrived shortly after and was present to assist with the facility inspection on today's date.

The facility is licensed for Eighty (80) Non-Ambulatory residents, of which four (4) may be bedridden with approved hospice waiver for Fifteen (15) residents. Currently, there are five (5) Hospice residents present during today’s visit. Facility is a two story building with 59 units combined in both Assisted Living and Memory Care with total capacity of 80. Facility is approved for Delayed Egress. Facility serves as a Residential Care Facility For Elderly and Dementia Residents.

At around 9:00AM, LPA’s conducted a tour of the physical plant accompanied by Executive Director Jennifer Munoz, and the following was observed: There were no bodies of water on the premises. Rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bathrooms were operational with water temperature measured between 110.8 to 116.4 degrees F inside facility restrooms. A comfortable temperature of 72 degrees F. was maintained in the facility. The kitchen was inspected, and facility has sufficient perishable and non-perishable foods. Facility has Easy Meal food kits which serve 25 individuals per package for emergency food and two large water drums of emergency water. Storage areas for sharps objects and cleaning supplies were stored and not accessible to residents. Facility has multiple fire extinguishers. During today’s visit eight (8) fire extinguishers were observed to be fully charged, mounted and in compliance with date of service of November 12, 2024. Facility has total of two evacuation chairs at end of each stairwell.


CONTINUED ON 809C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jenifer Tirre
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2025
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 AT LA PALMA
FACILITY NUMBER: 306006451
VISIT DATE: 08/01/2025
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A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

During the visit, LPA’s observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA’s observed the facility has supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA’s observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 7/18/2025. Facility has operating smoke detectors and audible alarms which LPA's observed Last fire inspection paperwork was completed by TRL Systems completed on March 5, 2025. Proof of liability insurance was provided during visit. The facility has current liability insurance on file effective 5/1/2025 – 5/1/2026.


A review of seven residents (R1-R7) service files and eight staff (S1-S8) personnel files revealed to be complete. Interviews were conducted with staff and residents.
The facility has the current administrator's certification on file for Jennifer Munoz # 7003108740 - Expiration 10/27/2025

No deficiencies during this inspection visit.

An exit interview was conducted with Executive Director Jennifer Munoz , and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jenifer Tirre
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC809 (FAS) - (06/04)
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