374604455-5-16-2025-08-AS-APAO-DGWNA8-20250522101706

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604455
Report Date: 05/14/2025
Date Signed: 05/16/2025 02:20:02 PM

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
03/10/2025 and conducted by Evaluator Ramon Serrano

COMPLAINT CONTROL NUMBER: 08-AS-20250310095341

FACILITY NAME:	IVY PARK AT OTAY RANCH		FACILITY NUMBER:	374604455
ADMINISTRATOR:	CALAIS ANGUIANO		FACILITY TYPE:	740
ADDRESS:	1290 SANTA ROSE DRIVE		TELEPHONE:	(619) 779-7400
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY:	137	CENSUS: 113	DATE:	05/14/2025
		UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Calais Anguiano		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff did not prevent residents from eloping from facility
Staff did not report incidents to appropriate parties

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 allegations. The investigation consisted of LPA observation, records review, interviews with staff, residents and outside sources.

It was alleged that facility staff did not prevent Resident 1 (R1) and Resident 2 (R2) from eloping from the facility. It was also alleged that staff did not report these incidents to appropriate parties. It was reported that R1 eloped from the memory care unit, walked a long distance and was gone from the facility for more than one hour. R1 was said to have been found by Staff 1 (S1). It was also reported that R2 eloped from the memory care unit, walked down a main road near the facility and was located by Staff 2 (S2) while they were driving to work.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

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 4

Control Number 08-AS-20250310095341

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: 05/14/2025

NARRATIVE

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LPA attempted to interview R1 on May 14, 2025. R1 was unable to answer qualifying questions. R1 was unable to state the date or time. LPA then asked R1 basic questions regarding leaving the facility unattended. R1 stated that they have left the facility in the past but not recently.

LPA interviewed R2 who stated that they have lived at the facility too long. R2 stated that they were recently thinking about walking across the street and catching a bus. R2 stated that in the past when they tried to leave the facility unsupervised a staff member yelled at them to get their walker. R2 stated that last month they left the facility and walked to the intersection by themselves.

LPA interviewed S1 who stated that the memory care unit was conducting an "elopement drill" right before the incident occurred with R1. S1 stated that the caregiver assigned to R1's section claimed that they "cleared their section." S1 stated that the egress door alarm sounded a short time after and the staff conducted a head count of residents. S1 stated that as they were driving away from the facility they saw R1 outside on the sidewalk area. S1 stated that they placed R1 in their car and drove them back to the facility. S1 stated R1 had no injuries and they estimate that R1 was out of the facility for approximately 10 minutes before R1 was located.

LPA interviewed S2 who stated that while driving to work on April 26, 2025 they saw R2 walking towards the street intersection of Olympic Parkway and East Palomar Street. S2 stated that they were worried and immediately called their supervisor to advise them where R2 was located. S2 stated that they do not believe R2 had any injuries as a result of the elopement. S2 stated that R2 lived in the assisted living section of the facility and has eloped from the facility more then three times.

LPA interviewed Outside Source 1(OS1) who stated that the facility staff called them immediately after the incident and advised OS1 that R1 "got out of the facility through the back." OS1 stated that the Director contacted OS1 the following day and was apologetic for what occurred. OS1 stated that they do not believe it was a major incident since their were no injuries and R1 simply slipped out. OS1 stated that R1 has never eloped before and they have full confidence in the facility staff.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250310095341

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: 05/14/2025

NARRATIVE

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LPA interviewed Executive Director (ED) who stated that on the date of the incident memory care staff were conducting an "elopement drill" and R1 exited the unit. ED stated that the alarm sounded and a head count and room checks were conducted. ED stated that care staff did not accurately count the residents and failed to alert that R1 was missing. ED stated when staff checked the memory care exit door area R1 had walked to far along to be seen. ED stated that the care staff that did not accurately count the residents was place on suspension and was later terminated. ED stated that R2 goes out for walks since their physician's report states they can leave the facility unassisted. ED stated that R2 did walk to the intersection by the facility and R2's family just requests that they do not get lost.

Records review revealed an incident report for R1 was submitted to CCL on March 13, 2025. Incident report stated that on March 6, 2025 the memory care egress door alarm sounded off at 410pm. Facility staff did not locate a resident in the surrounding area and conducted a head count. Facility staff located R1 at 417pm outside of the community, walking on the sidewalk. No injuries were noted. Records review revealed R1 had a diagnosis of Alzheimer's. R1 was unable to leave the facility unassisted and R1 was a high elopement risk due to resident expressing they wanted to leave the facility.

Records review revealed R2 had a diagnosis of Encephalopathy and a traumatic brain injury with loss of consciousness. R2's physician's report indicated that R2 was non-ambulatory and R2 was able to leave the facility unassisted at their families discretion. R2's care plan stated that R2 had a cognitive impairment, was unable to leave the community unsupervised and they are required to wear a safety bracelet if in assisted living.

The Department has investigated the complaint alleging staff did not prevent residents from eloping from facility and staff did not report incidents to appropriate parties. Based on evidence obtained R1 and R2 eloped from the facility and R2's elopement was not reported to the licensing agency. Accordingly, the above allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. The deficiencies are cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D.

An exit interview was conducted, plans of correction were jointly developed, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Calais Anguiano, Executive Director. Signature on this form confirms receipt of the documents.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20250310095341

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: 05/14/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/09/2025 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f)(1).... “Care and Supervision” means the facility assumes responsibility for…on going assistance with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to conduct training by an outside source on elopements/absent without leave (AWOL), supervision for residents in care. This training will be completed by POC date of 6/9/25. Licensee will provide LPA with a signed training roster and training agenda.
	8 9 10 11 12 13 14	Based on interview and record review, two residents (R1 and R2) wandered from the facility without required supervision. This posed an immediate health, safety, and personal rights risk to 2 of 109 residents in care.	8 9 10 11 12 13 14
Type B 06/09/2025 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	REPORTING REQUIREMENTS 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. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated the incident report would be completed and submitted to the licensing agency by POC date and a facility training will be conducted on "reporting requirements"
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee failed to report R2's elopement to law enforcement and the licensing agency. 1 in 1 of 109 persons in care [R2] This posed a potential health and safety risk to R2.	8 9 10 11 12 13 14	This is an amended version of a report originally delivered on 5/14/25.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

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