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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604455
Report Date: 02/14/2024
Date Signed: 02/14/2024 04:33:01 PM


Document Has Been Signed on 02/14/2024 04:33 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:IVY PARK AT OTAY RANCHFACILITY NUMBER:
374604455
ADMINISTRATOR:CALAIS ANGUIANOFACILITY TYPE:
740
ADDRESS:1290 SANTA ROSE DRIVETELEPHONE:
(619) 779-7400
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:137CENSUS: 114DATE:
02/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Health Services Director Brittany BlaulTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Health Services Director Brittany Blaul.

Today's visit was in response to two (2) SOC341 Reports of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/07/2023 and 02/01/2024, respectively). Per the first SOC341: it was alleged that Resident #1 (R1) had around $300 in cash stolen from their wallet sometime between 11/21/2023 and 12/06/2023. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Per the second SOC341: R1 had another $250 in cash stolen from their wallet sometime between 01/29/2024 and 01/31/2024.

During today’s visit, LPA performed a brief facility tour and collected copies of and reviewed pertinent care and personnel records, visitor logs, theft logs, and investigative notes. LPA also interviewed relevant staff. R1, who was a hospice care patient, passed away on 02/09/2024 and was unable to be directly interviewed by CCLD.

Regarding the first theft incident (i.e., $300) against R1, records and staff interviews showed: Licensee learned of the cash loss from R1’s responsible person (RP). Licensee timely reported the loss to CCLD, the Long-Term Care Ombudsman Program (LTCOP), and local police (CVPD). Per manager interview, Licensee’s internal investigation involved interviewing R1, who at that time, was of sound mind and a reliable historian. R1 told Licensee that they clearly saw Staff #1 (S1) take $300 in cash from their wallet. A review of personnel records showed that Licensee ended S1’s employment on 12/15/2023 for an unrelated reason, per the written termination notice. However, manager interview revealed that R1’s testimony about the first theft incident was a contributing factor towards R1’s termination of employment. The facility’s LIC9060 Theft and Loss Record corroborated that one of the “Action[s] Taken / Follow Up” for the first theft incident against R1 included “term of employee.” [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: IVY PARK AT OTAY RANCH
FACILITY NUMBER: 374604455
VISIT DATE: 02/14/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

Regarding the second theft incident (i.e., $250) against R1, records and staff interviews showed: Licensee learned of the cash loss from R1’s RP. Licensee timely reported the loss to CCLD, LTCOP, and CVPD. Per manager interview: Licensee’s internal investigation involved interviewing R1, outside sources, and facility frontline staff who were assigned to R1 during the date range of the loss (which was after S1 was no longer working at the facility). Interviews of frontline staff did not reveal any breakthrough in the second case. R1 by the date of the second investigation was less alert, as they were nearing end of life. Manager interview, corroborated by hospice visit notes and the facility’s visitor log, showed: During the date range of the second loss, R1 was visited inside their bedroom by multiple outside personnel, to include hospice agency staff and durable medical equipment (DME) company staff. Hospice notes showed R1 was asleep during at least two of these visits.

A preponderance of evidence exists to show that on at one occasion, Licensee’s staff (S1) did not ensure that a resident in care (R1) was protected from theft or loss. One (1) deficiency was cited per California Code of Regulations, Title 22 (see attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

LPA also issued one (1) Technical Violations (TV) per California Health and Safety Code, regarding delayed-egress door signs (see LIC 9102-TV page).

An exit interview was conducted with Blaul, to whom a copy of this report, the LIC809-D page, the LIC9102-TV page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/14/2024 04:33 PM - 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: IVY PARK AT OTAY RANCH
FACILITY NUMBER: 374604455

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2024
Section Cited
CCR
87468.2(a)(25)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents…shall have all of the following personal rights: “(25) To protection of their property from theft or loss…” This requirement was not met, as evidenced by:
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Per manager interview and personnel and training records: S1’s employment ended on 12/15/2023, resolving the immediate risk. Licensee also retrained remaining frontline staff on its Theft and Loss Policy on 12/28/2023. Licensee agreed to retrain remaining frontline staff on Resident’s Personal Rights (see from LIC613-C), and to submit the training sign-in sheet to LPA by 03/14/2024.
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Based on records and interviews, licensee’s staff (S1) did not ensure that 1 of 114 residents (R1) was protected from theft of loss, which posed an immediate personal rights 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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