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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006463
Report Date: 09/23/2026
Date Signed: 09/23/2026 11:30:03 AM

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
09/16/2026 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260916134233
FACILITY NAME:IVY PARK AT FULLERTONFACILITY NUMBER:
306006463
ADMINISTRATOR:MATSUMOTO, CHRISTINAFACILITY TYPE:
740
ADDRESS:2226 NORTH EUCLID STREETTELEPHONE:
(714) 738-3656
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:85CENSUS: 75DATE:
09/23/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Executive Director Christina MatsumotoTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff does not ensure transport vehicle used for residents is maintained in safe operating condition
Resident sustained injury due to staff not securing them properly
INVESTIGATION FINDINGS:
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On September 23, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegations listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director Christina Matsumoto was notified and later arrived to assist with the visit.

During the course of the investigation, the Department inspected the facility's transportation vehicle, conducted staff interviews, a resident interview, reviewed and obtained pertinent documents for this complaint. Regarding the allegation that, staff does not ensure transport vehicle used for residents is maintained in safe operating condition, the following has been concluded: During the investigation, the Department inspected the transport vehicle that is used for residents in care. The Department observed the vehicle to be in good condition with no apparent safety concerns. The Department also tested each seat belt and strap located in the vehicle and observed them to be operational.
CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
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-20260916134233
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: 09/23/2026
NARRATIVE
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During the investigation, the Department also obtained the last three inspection reports for the facility's transportation vehicle. The inspection reports were dated April 14, July 14, and September 21, 2026. The Department observed that the inspection reports did not indicate any needed repairs or any hazards that would make the vehicle unsafe to use.

Regarding the allegation that, resident sustained injury due to staff not securing them properly, the following has been concluded: During the investigation, it was revealed that on September 8, 2026, Resident #1 (R1) was being transported to a scheduled appointment by Staff #1 (S1) in one of the facility's transportation vehicles. During the transport, S1 encountered a pothole which caused the vehicle to suddenly rise and fall. R1 then complained of pain to their back. S1 then pulled the vehicle over and called Staff #2 (S2), and 9-1-1. R1 was then transported to the hospital as a result of an injury sustained. During the investigation, the Department conducted interviews with all individuals involved, including R1, S1, and S2. During the interview with R1, R1 was unable to state if they were, or were not properly secured, during the transport. During the interview with S1, S1 denied the allegation and reported that they properly secured R1 before the transport by using the appropriate belt and straps. During the interview with S2, S2 reported that they observed R1 to be properly secured when they arrived to further assess R1. The Department was unable to gather any evidence during the investigation to support the complaint allegation.

Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the two allegations above are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Christina Matsumoto and a copy of the report was provided at time of visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
09/16/2026 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260916134233

FACILITY NAME:IVY PARK AT FULLERTONFACILITY NUMBER:
306006463
ADMINISTRATOR:MATSUMOTO, CHRISTINAFACILITY TYPE:
740
ADDRESS:2226 NORTH EUCLID STREETTELEPHONE:
(714) 738-3656
CITY:FULLERTONSTATE:CAZIP CODE:
92835
CAPACITY:85CENSUS: 75DATE:
09/23/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Executive Director Christina MatsumotoTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff does not ensure reporting requirements are followed
INVESTIGATION FINDINGS:
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On September 23, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegation listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director Christina Matsumoto was notified and later arrived to assist with the visit.

During the course of the investigation, the Department conducted staff interviews, a resident interview, reviewed and obtained pertinent documents for this complaint. Regarding the allegation that, staff does not ensure reporting requirements are followed, the following has been concluded: California Code of Regulations, Title 22 Section 87211(a)(1)(d) states the following: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.
CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20260916134233
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: 09/23/2026
NARRATIVE
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 This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." During the investigation, it was revealed that on September 8, 2026, Resident #1 (R1) sustained a compression fracture to their T7 vertebral body as a result of an incident that occurred while R1 were being transported to a scheduled appointment. During the transport, the driver of the facility vehicle encountered a pot hole, and R1 complaining of back pain afterwards. R1 was subsequently transported to the hospital as a result of injury sustained, and therefore, a written report documenting this incident was required, since it impacted the health and safety of R1. The Department also reviewed R1's after visit discharge summary which confirmed that R1 sustained a compression fracture to their T7 vertebral body. During the investigation, the Department conducted interviews with R1 and staff who were witnesses to the incident that occurred on September 8, 2026. All individuals interviewed confirmed that the incident occurred and that R1 sustained an injury. The Department observed that the facility submitted an Unusual Incident/Injury Report to the Orange County Regional Office that confirmed the incident regarding R1 on September 8, 2026. The Unusual Incident/Injury Report was dated September 16, 2026, and sent to the Orange County Regional Office on the same day. Therefore, the Unusual Incident/Injury Report was not created, or submitted to the Orange County Regional Office within the seven day required time frame.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, staff does not ensure reporting requirements are followed. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D page. An exit interview was conducted with Executive Director Christina Matsumoto. A copy of the report and appeal rights were provided at time of visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20260916134233
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2026
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports.. (1) A written report shall be submitted to the licensing agency .. within seven days..(D) Any incident which threatens the welfare, safety or health of any resident..
This requirement was not evidence by:
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The Executive Director stated that she will complete a written statement that the facility will abide by the regulation cited. The Executive Director agreed to provide LPA the written statement via email or fax by POC due date.
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Based on interviews and records reviewed, the Licensee did not ensure that the facility submitted a written report to the Department regarding Resident #1 (R1) injury on September 8, 2026, within the required 7 day time frame. This poses a potential health and safety risk to persons in care.
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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: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5