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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604455
Report Date: 05/21/2024
Date Signed: 05/21/2024 10:12:18 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2023 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20230518133003
FACILITY NAME:IVY PARK AT OTAY RANCHFACILITY NUMBER:
374604455
ADMINISTRATOR:KAPLIOFF, ANGELAFACILITY TYPE:
740
ADDRESS:1290 SANTA ROSE DRIVETELEPHONE:
(619) 779-7400
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:137CENSUS: 85DATE:
05/21/2024
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Business Office Director Silvia GarciaTIME COMPLETED:
10:25 AM
ALLEGATION(S):
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Neglect/lack of supervision resulted in resident sustaining head injury.
Licensee did not address resident's change in condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced a follow up complaint investigation visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Business Office Director Silvia Garcia.

Throughout the investigation, the Department secured records and conducted interviews with external and internal sources.

It was alleged neglect/lack of supervision resulted in a resident sustaining a head injury. On 05/18/2023, the Department received an SOC 341, a report of Suspected Dependent Adult/ Elder Abuse. It was reported Resident # 1 (R1) had sustained an unwitnessed fall on 5/3/23 and was transported to the hospital for further evaluation. On 5/4/23, 911 was again called to the facility as R1 had sustained another fall resulting in head trauma.
(See LIC 9099C form for continuation of report.)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
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 3
Control Number 08-AS-20230518133003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: IVY PARK AT OTAY RANCH
FACILITY NUMBER: 374604455
VISIT DATE: 05/21/2024
NARRATIVE
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R1 was an 88 year resident considered non- ambulatory due physical and mental state, required supervision when ambulating with a walker, required assistance with escorts, and was diagnosed with Dementia, hypertension, and general weakness among other comorbidities.

Interviews with internal sources revealed R1 resided at the facility from 4/27/23 to 5/5/23. The facility staff had conducted visual checks on R1 every two hours, or less. After the initial fall was reported, interviews consistently revealed R1 was placed on alert charting, which increased the frequency of each check to every hour and staff spent more time with R1 during each check. It was believed R1’s bed was high off the ground, not appropriate and a possibly contributed to the falls. Interviews consistently disclosed staff had notified R1’s family R1’s bed may not be appropriate, but family declined to provide a lower bed. During the second fall on 5/4/23, staff reported family and staff had interacted with R1 prior to the fall. Staff had checked on R1 approximately twenty minutes prior to the fall, and staff had witnessed R1’s family exiting the room after.

Interviews with external sources revealed R1’s family believed the facility was understaffed, because R1’s spouse, who resided with R1, was once found with a soiled undergarment. It was confirmed R1 no longer resided at the facility, and R1’s had a lower hospital bed which made it easier for R1 to ger in and out.

Although a review of records revealed R1 was considered non-ambulatory, was a fall risk, and required assistance with being supervised when ambulating with a walker, there was not enough evidence to support staff negligence resulted in R1 sustaining injuries. Both incidents were unwitnessed, staff responded and summoned medical attention, therefore, the allegation was Unsubstantiated.

It was alleged the licensee did not address resident's change in condition. Review of incident reports along with interviews confirmed R1 had two unwitnessed falls. The first fall occurred on 5/3/23, R1 was found by staff, was transported for medical attention, and returned with not injuries noted. The second fall occurred on 5/4/23, R1 was found with a facial laceration and was transported for medical attention. Interviews consistently revealed staff had conducted wellness checks on average every two hours. After the initial fall, management relayed R1 would be placed on alert requiring hourly wellness checks. Staff confirmed alert charting, hourly wellness checks, and observation was increased for R1. Although a higher bed was identified as a possible contributor to R1’s falls, and a care conference may have been scheduled to discuss appropriate level of care, there was not enough evidence to prove staff did not address R1’s change of condition.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230518133003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: IVY PARK AT OTAY RANCH
FACILITY NUMBER: 374604455
VISIT DATE: 05/21/2024
NARRATIVE
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An exit interview was conducted with Business Office Director , to whom a copy of this report, LIC 811 Confidential names list and Licensee/Appeals Rights (LIC 9058,) were provided
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3