<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006456
Report Date: 08/06/2026
Date Signed: 08/06/2026 04:24:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/30/2026 and conducted by Evaluator Eboni Bentley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260730160148
FACILITY NAME:IVY PARK AT HUNTINGTON BEACHFACILITY NUMBER:
306006456
ADMINISTRATOR:REAMER-YU, BRYANFACILITY TYPE:
740
ADDRESS:7401 & 7351 YORKTOWN AVE.TELEPHONE:
(714) 536-3032
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY:142CENSUS: 117DATE:
08/06/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Bryan Reamer-Yu - AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate supervision, resulting in resident eloping and sustaining an injury.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On August 6, 2026, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced visit for the purpose of initiating the complaint investigation into the above allegation. LPA was greeted and granted entry after stating the purpose of the visit to staff. Administrator (Admin) Bryan Reamer-Yun arrived a short time later to assist with the investigation.

On July 30, 2026, the Department received the complaint regarding Resident #1 (R1’s) elopement. During the course of the investigation, LPA interviewed staff, resident, and a witness. The following documentation was observed and reviewed: Personnel Report Summary (LIC500), Resident Roster, Face Sheet, Physician's Report, Needs and Services Plans, Charting Notes, Internal Incident Report, Medication Administration Record (MAR), Home Health Records, Medical Records, and Staff Training Logs.

CONTINUE TO LIC9099-C PAGE....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 22-AS-20260730160148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HUNTINGTON BEACH
FACILITY NUMBER: 306006456
VISIT DATE: 08/06/2026
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
26
27
28
29
30
31
32
The investigation revealed the following:

Regarding the allegation, Staff did not provide adequate supervision, resulting in resident eloping and sustaining an injury, it is alleged that staff did not ensure the resident’s safety and did not report the incident in a timely manner. On July 31, 2026, the Department received an incident report regarding Resident #1 (R1) eloping and leaving the facility unattended on July 29, 2026, from 1pm-1:50pm. On August 3, 2026, LPA conducted a telephone interview with Admin who stated they wanted to provide additional information regarding the elopement incident previously reported by telephone and email. Admin stated that based on their investigation, it appears the resident may have climbed over the fence in the backyard. The fence is approximately six feet tall, and the resident's walker was found adjacent to the fence with dirt on the bench of the walker. Admin stated there were no witnesses, however, they think R1 climbed on their walker and then climbed over the gate, resulting in a fall. Admin stated R1 did not attend lunch and was last observed by their assigned caregiver at approximately 12:35 pm, resting in bed. Admin stated they subsequently learned that the Huntington Beach Fire Department (HBFD) located R1 at approximately 1:50 pm, evaluated the resident, and transported R1 to Orange Coast Memorial Hospital. Per interview with Witness #1 (W1), R1 was found 1.1 miles away from facility and sustained a "mechanical trip and fall with a head injury" on a city sidewalk. When asked if the fall occurred in or near the facility, W1 stated no, that the fall happened away from the facility and on the city sidewalk. When HBFD located R1, and after some questioning, it was determined that R1 lived at Ivy Park. HBFD contacted the facility and asked if this was a resident of lvy Park, to which they confirmed R1 was. W1 stated staff were not aware that R1 had left the facility and did not know R1 was missing for an unknown amount of time. A record review of the Physician’s Report dated October 8, 2025, lists a diagnosis of Dementia and Cognitive Communication Deficit. Medical records dated July 29, 2026, indicate R1 was evaluated for a head injury and released on the same date. Hospice records dated July 31, 2026, state R1 was assessed and observed with a right eyebrow scar bruise extending to right cheek and right side of neck, right lateral hip bruise approximately 3 x 3 inches, and right lower palm inch skin abrasion with 1 x 2 inches. Charting notes dated created on July 26, 2026, state staff observed R1 on July 24, 2026 at 12pm “exiting seeking” as R1 “tried to open the outside gate.. tried to grab a table to climb over but was not successful.”


CONTINUE TO LIC9099-C PAGE....
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20260730160148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HUNTINGTON BEACH
FACILITY NUMBER: 306006456
VISIT DATE: 08/06/2026
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
26
27
28
29
30
31
32
The investigation revealed that facility staff failed to provide adequate supervision on July 29, 2026, resulting in resident eloping and sustaining a head injury. The resident vacated the facility unattended, crossed a major city street, and was outside of the facility long enough to walk 1.1 miles away from the facility until a by standard located them and called the authorities. Additionally, facility staff did not report the incident to the Department within the required time frame. The memory care units are located on two floors in one building “Evergreen 1 & 2”, and one the ground floor in a separate building across the parking lot called “Evergreen 3/ The Cottages”. While conducting an inspection of all egress doors with the Admin, LPA observed one egress in Evergreen 2, leading to a stairwell, non-operational, with no alarm sounding or alerting staff pagers. After 30 + seconds, the door did not release and Admin called staff to attempt repair. In Evergreen 3, LPA observed an egress door being held for 45 seconds before releasing. All other egress doors released between 15-30 seconds after being held.

Based on observation, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff did not provide adequate supervision, resulting in resident eloping and sustaining an injury, is deemed SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D. CIVIL PENALTY ASSESSED.

An exit interview was conducted with Administrator Bryan Reamer-Yun, and a copy of this report, LIC9099-D, LIC421, Confidential Names (LIC 811), and appeal rights were provided at exit.
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Citations on this Visit Report are Under Appeal!

Control Number 22-AS-20260730160148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HUNTINGTON BEACH
FACILITY NUMBER: 306006456
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2026
Section Cited
CCR
87468.1(a)(2)
1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all ... (2) To be accorded safe, healthful and comfortable accommodations..

This requirement is evidenced by:
1
2
3
4
5
6
7
Administrator shall ensure that supervising staff are trained on elopement within 24 hours.The facility will review and update R1's care plan and implement measures to reduce future falls and elopements. Documentation of staff training and care plan updates will be submitted to CCLD by 8/7/2026 to eboni.bentley@dss.ca.gov.

IMMEDIATE CIVIL PENALTY ASSESSED
8
9
10
11
12
13
14
Based on observation, interview, and record review, the Licensee failed to adequately supervise (R1) on 7/29/2026, which posed an immediate risk to residents in care. R1 left the facility unattended (eloped), walked 1.1 miles away from the facility, and sustained a head injury.
8
9
10
11
12
13
14
Under Appeal
Type A
08/15/2026
Section Cited
CCR
87211(a)(2)
1
2
3
4
5
6
7
87705 Care of Persons with Dementia (e) Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements...

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will contact vendor to evaluate all egress doors and repair as needed. If vendor is not available to service doors before POC due date, Administrator will send video proof that the egress door is working properly or assign staff to monitor the door on a continualy basis until repaired. Proof will be submitted to CCLD via eboni.bentley@dss.ca.gov by POC due date.
8
9
10
11
12
13
14
Based on observation, the facility did not ensure all egress doors were working properly, which poses an immediate risk to residents in care. LPA observed one non-operational egress door, with no alarm sounding or alerting staff pagers in Evergreen 2 and an egress door in Evergreen 3, being held for 45 seconds before releasing.
8
9
10
11
12
13
14
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: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Citations on this Visit Report are Under Appeal!

Control Number 22-AS-20260730160148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HUNTINGTON BEACH
FACILITY NUMBER: 306006456
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
08/13/2026
Section Cited
CCR
87211(a)(2)
1
2
3
4
5
6
7
87211 Reporting Requirements (a) Each
licensee shall furnish to the licensing agency such reports as the Department may require... (2)Occurrences, such as.. major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours .. to the licensing agency and to the local health officer when appropriate.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator will train all staff on reporting requirements and submit proof of attendees to CCLD via eboni.bentley@dss.ca.gov by POC due date.
8
9
10
11
12
13
14
Based on observation, interview, and record review, the facility did not report the elopement to the Department within 24 hours, which poses a potential Health, Safety, and Personal Rights risk to persons in care. Records reviewed corroborated that R1 eloped on 7/29/2026 and the incident was not reported within the required time frame.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5