306006463-4-17-2025-22-AS-LMOA-DG92TA-20250430174025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006463
Report Date: 04/17/2025
Date Signed: 04/17/2025 05:14:23 PM

Unsubstantiated

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
04/09/2025 and conducted by Evaluator Edward Kim

COMPLAINT CONTROL NUMBER: 22-AS-20250409155948

FACILITY NAME:	IVY PARK AT FULLERTON		FACILITY NUMBER:	306006463
ADMINISTRATOR:	HALE, CHRISTINA		FACILITY TYPE:	740
ADDRESS:	2226 NORTH EUCLID STREET		TELEPHONE:	(714) 738-3656
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY:	85	CENSUS: 62	DATE:	04/17/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Director- Kathleen Olson		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff did not ensure resident's hygiene needs were met
Staff did not ensure facility was cleaned properly
Staff did not ensure resident's bathroom had toilet paper

INVESTIGATION FINDINGS:

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On April 17, 2025, at 8:00 AM Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit at the above facility for the above allegations. LPA Kim met with Director Kathleen Olson and LPA explained the purpose of the visit.

During today's visit, LPA Kim conducted a Health and Safety check, and no concerns were observed. LPA Kim reviewed and obtained copies of one (1) resident record, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans, and other pertinent records. LPA obtained residents roster, staff roster, and staff schedule. LPA Kim conducted one (1) resident interviews, two (2) witness interviews, and six (6) staff interviews.

The investigation revealed the following:

CONTINUED ON LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250409155948

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 FULLERTON	FACILITY NUMBER: 306006463
	VISIT DATE: 04/17/2025

NARRATIVE

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Staff did not ensure resident’s hygiene needs were met
It is alleged that resident diagnosed with dementia has long nails, unwashed (greasy) and unbrushed hair due to lack of care. Reporting Party reported noticing resident was using another resident’s shampoo products.

Based on record review, physician’s report dated October 17, 2024, shows the resident has dementia; has the capability for self-care by being able to bath self, able to dress/groom self, and able to care for own toileting needs. Per Pre-appraisal dated October 18, 2024, resident only needs prompting with bathing, hair care, personal hygiene. A shower log indicates R1 refused to take a shower on February 28, 2025.

Based on interviews conducted, six out of six staff denied that staff did not ensure resident’s hygiene needs were met. Two out of two witnesses claimed staff did not ensure resident’s hygiene needs were met. R1 stated that the facility met the resident’s needs and likes the staff. Staff would constantly ask multiple times per day to prompt resident to shower and/or brush their hair, resident would sometimes refuse.

Based on observation, during the visit LPA observed in the morning that R1 was with fifteen other residents in the activity room in the Memory Care wing are clean and well groomed. LPA observed the R1 having hair that was clean and brushed, and their nails were of normal length. LPA observed none of the shower products in R1’s bathroom had a different name on them. One shampoo was labeled with R1’s name and one lotion was labeled “A5.” Based on evidence gathered, there is no sufficient evidence gathered to corroborate the above allegation.

Staff did not ensure the facility was cleaned properly
It is alleged the facility was dirty.

Based on interviews conducted, six out of six staff denied the staff did not ensure the facility was cleaned properly. Two out two witnesses claimed the staff did not ensure the facility was cleaned properly. Witness #2 (W2) stated the resident’s bathroom was dirty with grime in the toilet and the sink. Interview with R1 confirms the facility including their bedroom clean and is satisfied with the condition of the bedroom.

CONTINUED ON LIC9099-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250409155948

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 FULLERTON	FACILITY NUMBER: 306006463
	VISIT DATE: 04/17/2025

NARRATIVE

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Based on record review, the cleaning schedule indicates each bedroom is cleaned once a week by the maintenance staff. Common areas are cleaned every day.

Based on observation, LPA observed the resident’s bedroom to be clean, sanitary, and in good repair. There was no smell, the sink and toilet were clean and operational, and the carpet was vacuumed. LPA observed housekeepers cleaning in common areas throughout the day, and cleaning assigned rooms according to schedule.

Based on evidence gathered, there is no sufficient evidence gathered to corroborate the above allegation.

Staff did not ensure resident’s bathroom had toilet paper.
It is alleged by the Reporting Party there was no toilet paper in resident’s bathroom.

Based on interviews conducted, six out of six staff denied staff did not ensure R1’s bathroom had toilet paper. One staff states in a bedroom there would be two rolls of toilet paper in the bathroom. Two out of two witnesses claimed the staff did not ensure R1’s bathroom had toilet paper. Interview with R1 confirmed they have enough toilet paper every day.

Based on observation, LPA Kim saw two rolls of toilet paper in the bathroom in R1’s bedroom. One was in the toilet paper holder in the bathroom and one on top of the toilet in reach of the R1.

Based on evidence gathered, there is no sufficient evidence gathered to corroborate the above allegation.

Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview was conducted a copy of the report was provided to Director Kathleen Olson.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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