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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604455
Report Date: 07/29/2024
Date Signed: 07/29/2024 11:29:08 AM

Substantiated


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
11/15/2021 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20211115095357
FACILITY NAME:IVY PARK AT OTAY RANCHFACILITY NUMBER:
374604455
ADMINISTRATOR:WILLIAMS, REBECCAFACILITY TYPE:
740
ADDRESS:1290 SANTA ROSE DRIVETELEPHONE:
(619) 779-7400
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:137CENSUS: 113DATE:
07/29/2024
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Calais AnguianoTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Staff neglected resident resulting in hospitalization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Calais Anguiano and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA direct observation, records review and interviews with facility staff.

It was alleged that staff neglected Resident 1 (R1) resulting in hospitalization.[an LIC 811 Confidential Names List was provided to the facility representative to identify the resident.]It was reported that R1 fell in their room and called for staff assistance multiple times. An outside party called emergency services for R1 and R1 was transported to the hospital. Interviews were conducted with seven staff members, during this time period. Of the seven staff members, all reported that staffing was an issue and five of the seven reported that either residents did not get care and/or the residents had to wait a while to receive the care.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
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 5
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
11/15/2021 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20211115095357

FACILITY NAME:IVY PARK AT OTAY RANCHFACILITY NUMBER:
374604455
ADMINISTRATOR:WILLIAMS, REBECCAFACILITY TYPE:
740
ADDRESS:1290 SANTA ROSE DRIVETELEPHONE:
(619) 779-7400
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:137CENSUS: 113DATE:
07/29/2024
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Calais AnguianoTIME COMPLETED:
11:35 AM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff did not provide incontinence care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Calais Anguiano and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observation, records review and interviews with facility staff and outside sources.

It was alleged that staff did not provide incontinence care for Resident 2 (R2) [an LIC 811 Confidential Names List was provided to the facility representative to identify the residents.] It was reported that R2 was left in R2's feces and was not bathe for a week. Review of outside agency records revealed R2 was regularly monitored and observed by a Licensed Vocational Nurse. Outside agency care notes dated July 2021 through October 2021 included R2's vital signs, LVN's observations and any recommendations.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20211115095357
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: 07/29/2024
NARRATIVE
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Agency care notes indicated that R2 was awake, alert and verbally responsive. No reports of pain or cough noted. Recommendations included; keep nails trimmed and apply sarna lotion prn. Outside agency did not observe or document R2 being left in feces or unbathed.

Facility internal care notes dated May 2021 through April 2022 indicate R2 was regularly monitored and assessed by facility staff. Care notes indicate R2 was monitored for both R2's mental and physical well being. R2's responsible party was also advised of any change of condition. R2's service plan dated Jan 1, 2022 indicated that R2 needed assistance with incontinence supplies, hygiene, and changing linens. R2 would be toileted day and night. Service plan further indicated that R2 would receive assistance with toileting according to R2's schedule, need, and requests.

Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid.

An exit interview was conducted with Calais Anguiano. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Calais Anguiano whose signature below verifies receipt of these rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20211115095357
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: 07/29/2024
NARRATIVE
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The other two staff members acknowledged that staffing was a problem and they are often required to work very hard but that resident's needs were being met.

Review of internal logs was conducted. The call alert logs from the facility reflected an ongoing concern with long wait times for care. In one week analyzed over 13% of resident calls were answered after 20 minutes or more. Some resident calls took over an hour to answer.

LPA interviewed Executive Director (ED) who stated that she began working at the facility on July 2023. ED stated that as of today the facility is sufficiently staffed and the resident pendant calls are answered on a timely basis. ED further stated that the response call time has also improved from the previous year.

Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D.

An exit interview was conducted with Calais Anguiano and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Calais Anguiano whose signature below confirms receipt of documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20211115095357
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2024
Section Cited
CCR
87464(f)(4)
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87464 Basic Services
(f) (4) Basic services shall at a minimum include, personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living. This requirement was not met as evidence by:
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Facility managment will conduct in-service trainings with all staff to ensure call buttons are attended within the standard response time.
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Based on interviews and records review, the licensee did not ensure that residents received personal assistance and care as needed on a timely basis to meet the residents’ needs. This posed a potential health risk to residents 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: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5