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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006451
Report Date: 09/26/2024
Date Signed: 09/26/2024 11:51:09 AM


Document Has Been Signed on 09/26/2024 11:51 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 LA PALMAFACILITY NUMBER:
306006451
ADMINISTRATOR:MUNOZ, JENNIFERFACILITY TYPE:
740
ADDRESS:5321 LA PALMA AVENUETELEPHONE:
(724) 739-8111
CITY:LA PALMASTATE: CAZIP CODE:
90623
CAPACITY:80CENSUS: 68DATE:
09/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jennifer MunozTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Tea conducted a case management visit to follow up on an incident report received by Community Care Licensing (CCL) on September 23, 2024 submitted by Executive Director (ED), Jennifer Munoz. LPA was greeted and allowed entrance into the facility by Executive Chef, Jeremai Soto and explained the reason for the visit. ED Munoz arrived shortly to assist during the visit.

During the case management visit, LPA and ED toured the facility. LPA conducted health and safety checks on residents present and confirmed they were doing well and observed no health and safety issues besides residents who have Covid-19. Facility is following public health Covid-19 protocol. LPA observed the facility to be clean and organized and found no health and safety issues. LPA checked perishable and non-perishable food supply and it was adequately stocked at time of visit.

The purpose of this visit is to discuss the special incident report (LIC624) submitted that occurred on September 13, 2024 around 8:15 PM where Staff 1 (S1) observed Staff 2 (S2) physically placed their hand over Resident 1’s (R1) mouth who resides in Memory Care. LPA requested resident file, staff files, staff and resident roster and internal investigation summary report. LPA interviewed with ED Munoz, Memory Care Director (MCD) Samantha Shashkin and R1.

S1 reported the incident at the end of their shift to the MCD Shashkin. ED Munoz conducted an internal investigation the following day, September 14, 2024. ED Munoz along with MCD Shashkin interviewed Memory Care staff, including S2 right before they started their shift. Management has pulled S2 off the floor and has placed them on administrative leave/suspension and employee status is pending after investigation. The ombudsman was contacted and local law enforcement was notified and reported the incident to them. The internal investigation was closed on September 18, 2024. Facility management concluded they were going to terminate S2 employment. (Report continued on LIC809-C)
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 09/26/2024
NARRATIVE
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There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s visit the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Executive Director, Jennifer Munoz and a copy of this report and appeal rights was provided at exit
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2024 11:51 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: IVY PARK AT LA PALMA
FACILITY NUMBER: 306006451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
87468.1(a)(1)

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Personal Rights of Residents in All Facilities ... Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Executive Director will conduct inservice training on Personal Rights of Residents and elderly abuse and provide proof of training by POC due date.
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This requirement is not met as evidenced by:

Based on LPA's investigation staff violated personal rights of resident by physically covering the mouth of the resident with their hand in order to subdue resident's reaction.
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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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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