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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604455
Report Date: 06/16/2026
Date Signed: 06/16/2026 12:45:06 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
05/30/2025 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20250530085015
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: 122DATE:
06/16/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Executive Director Diana WeinsteinTIME COMPLETED:
10:33 AM
ALLEGATION(S):
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Licensee did not arrange timely medical care for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegation. LPA was welcomed by, identified themself to, and discussed the purpose of the visit with Executive Director Diana Weinstein, who granted entry for the visit.

The Complainant alleged that the Licensee did not provide timely medical care for Resident 1 (R1) [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] It was explained that on 03/22/2025, R1 fell and hit their head on the ground, after which they had a subsequent decline in cognition. R1 was not evaluated until they were hospitalized on 03/29/2025 where they remained until their death on 04/25/2025.

The Department’s investigation involved multiple unannounced facility tours/welfare checks, interviews of pertinent staff and outside sources, and review of relevant medical, hospital, and facility care records.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
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 7
Control Number 08-AS-20250530085015
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: 06/16/2026
NARRATIVE
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There was no involvement from the San Diego County Medical Examiner’s office in this case. 

Per Licensee’s “Fall Management Protocol” written policy, all falls, witnessed or unwitnessed, require several response steps to include that “any resident sustaining a fall will also be placed on Alert charting status” and that “the [resident's] healthcare practitioner will be notified using Form 213a, Physician Fax Report of Fall.” As confirmed in administrator interview, Licensee defined “Alert charting” as the facility’s licensed nurse meeting with the resident face-to-face daily, for at least three (3) consecutive days after the fall, to assess the resident’s health and ask about their experienced symptoms, and to document these findings in electronic progress notes. During their 06/02/2025 site visit, LPA Nguyen requested from Licensee copies of the facility staff’s charting and/or progress notes, which would evidence that “Alert charting” was performed on R1 post-fall. However, facility managers replied that no such notes existed which could prove that R1 was placed on “Alert charting status,” as was required by Licensee’s own written policy. 

While the available evidence cannot prove that R1’s blood pressure was elevated during or shortly after their fall on 03/22/2025, or that staff had constructive knowledge of R1’s rising blood pressure, the facility plan of operation, and interviews with facility staff corroborate that the proper protocol was to have R1 medically assessed and continuously observed by competent medical authority after their fall. 
 
While there was not enough evidence to show that that the facility was ultimately responsible for R1’s death, [See related LIC 9099 for complaint control number 08-AS-20250530085015], there is a preponderance of evidence to show that R1 experienced a serious medical emergency for which they did not receive timely medical care. Therefore, the complaint is substantiated and deficiencies cited [see attached LIC 9099(d)]. The licensee is hereby notified that additional civil penalties are under review by the Department’s legal division per Health and Safety Code § 1569.49(f). 

An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. 
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20250530085015
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: 06/16/2026
NARRATIVE
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A review of the investigation and evidence was also performed by the Department’s Program Clinical Consultants (licensed medical professionals). 

According to their LIC603 Preplacement Appraisal, R1 was diagnosed with hypertension and hyperlipidemia when they moved into the facility. R1’s LIC602 Physician’s Report showed that both diagnoses were chronic and preexisting for years. Together, records and interviews showed that during the complaint timeframe: R1 was and remained independent in all their activities of daily living (ADLs), including mobility, transferring, and medication management. R1’s doctor wrote that R1 was not confused/disoriented, was able to follow instructions, and was able to communicate their own needs.  

Records and interviews showed: On 03/22/2025 around 7:50 PM, R1 was carrying food/groceries when they tripped and fell, landing on the welcome mat just outside the facility’s main entrance door. The fall was partially witnessed by Person #1 (P1). Receptionist Staff #2 (S2) observed R1 on the ground, right after the fall, and radioed caregiver Staff #3 (S3) for help. S2 and S3 went outside to assist R1. R1 got back up on their feet, with S3’s help. R1 insisted to these staff that they were fine/uninjured and declined to be evaluated by the medication technician on duty, Staff #3 (S3). Neither P1, S1, nor S2 observed any skin tear, mark, or bruise on R1’s head or body. The responding facility staff (S1 and S2) did not inform any medication tech, nurse, or manager about this fall. Instead, S2 escorted R1 back to their apartment/room.  
According to P1, they phoned R1 around 8:30 PM, at which time R1 told P1 they had a headache for which they would take a Tylenol. Neither P1 nor R1 mentioned R1’s headache to facility staff. 

Interviews of multiple facility staff and P1 aligned to show that R1 seemed normal over the next several days; R1 ate their meals in the dining room and act/spoke as usual. Then on 03/28/2025, P1 transported/escorted R1 to run errands outside the facility, and for the first time P1 noticed a change/decline in R1; specifically, P1 witnessed R1 struggle with separating their personal checks from the carbon copies, which was unlike R1. P1’s observation was communicated to facility staff the next day on 03/29/2025. Upon receiving this information, facility medication technician Staff #4 (S4) and nurse manager Staff #5 (S5) went to observe R1, finding that R1 was alert but confused compared to their baseline. Facility medication technician Staff #6 (S6) measured R1’s blood pressure at this time, finding it abnormally high at 251/102. Staff arranged for R1 to be transported to a local hospital emergency room (ER) via ambulance, where they remained hospitalized until their death. According to their official death certificate, R1’s immediate cause of death was “Acute Respiratory Failure,” secondary to “Nontraumatic Cerebral Intraventricular Hemorrhage” and “Hypertensive Emergency.”
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
05/30/2025 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20250530085015

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: DATE:
06/16/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Executive Director Diana WeinsteinTIME COMPLETED:
10:33 AM
ALLEGATION(S):
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 Licensee culpability in resident’s death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified themself to, and discussed the purpose of the visit with Executive Director Diana Weinstein, who granted entry for the visit.

The Complainant alleged that the Licensee was culpable for the death of Resident 1 (R1), who died several days after suffering a fall in the facility [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The Complainant explained that on 03/22/2025, R1 fell and hit their head on the ground, after which they had a subsequent decline in cognition. R1 was hospitalized on 03/29/2025 where they remained until their death on 04/25/2025.

The Department’s investigation involved multiple unannounced facility tours/welfare checks, interviews of pertinent staff and outside sources, and review of relevant medical, hospital, and facility care records.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
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 7
Control Number 08-AS-20250530085015
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: 06/16/2026
NARRATIVE
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According to their LIC603 Preplacement Appraisal, R1 was already diagnosed with hypertension and hyperlipidemia when they moved into the facility. R1’s LIC602 Physician’s Report showed that both such diagnoses were chronic and preexisting for years before the above fall. R1’s medical records corroborated these same diagnoses and showed R1 had prior history of cerebrovascular accident (aka “stroke”). R1 last met with their primary care physician on 01/06/2025 (over 3.5 months before the above fall); on that date R1’s elevated blood pressure (which was 190/51), along with “complex conditions case management,” was the treatment focus of said doctor's appointment. Together, records and interviews showed that during the complaint timeframe: R1 was and remained independent in all their activities of daily living (ADLs), including mobility, transferring, and medication management. R1’s doctor wrote that R1 was not confused/disoriented, was able to follow instructions, and was able to communicate their own needs. While some of R1’s prescribed medications at the time treated/related to high blood pressure, R1 was not on any blood-thinner type medications during the complaint timeframe. 

According to the National Institutes of Health, an intracerebral hemorrhage is “a severe type of stroke occurring when a ruptured blood vessel causes bleeding inside the brain, creating pressure, destroying brain tissue, and blocking oxygen,” and “it is often caused by chronic hypertension.” The NIH also reports, “Hypertension is the most common cause of spontaneous, primary intraventricular hemorrhage (PIVH) in adults, with high blood pressure causing small vessels to rupture. It typically presents with sudden headache, nausea, and altered consciousness.” 

With the available evidence, the Department concluded that R1’s fall on 03/22/2025 was not a proximate cause of R1’s elevated blood pressure; hypertension was a preexisting chronic condition for R1. While R1 arrived at the ER in a state of hypertensive crisis on 03/29/2025, R1’s stroke/cerebral hemorrhage occurred the following day while R1 was under hospital care, and not at the facility. Hospital staff determined R1’s stroke/cerebral hemorrhage was “nontraumatic,” meaning R1’s earlier fall on 03/22/2025 was not a proximate cause for the stroke/hemorrhage’s occurrence (8) days later, on 03/30/2025. The “nontraumatic” nature of the stroke/cerebral hemorrhage was reiterated on R1’s official death certificate.  

Based on records and interviews, a preponderance of evidence does not exist to support the allegation that the Licensee was culpable for R1’s death. Therefore, the allegation is unsubstantiated and no deficiencies are cited. An exit interview was conducted with Diana Weinstein, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. The report was amended for signatures.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20250530085015
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: 06/16/2026
NARRATIVE
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A review of the investigation and evidence was also performed by the Department’s Program Clinical Consultants (licensed medical professionals). 

Records and interviews showed: On 03/22/2025 around 7:50 PM, R1 was carrying food/groceries when they tripped and fell, landing on the welcome mat just outside the facility’s main entrance door. The fall was partially witnessed by Person #1 (P1). Receptionist Staff #2 (S2) observed R1 on the ground, right after the fall, and radioed caregiver Staff #3 (S3) for help. S2 and S3 went outside to assist R1. R1 quickly got back up on their feet, with S3’s help. R1 insisted to these staff that they were fine/uninjured and declined to be evaluated by the medication technician on duty, Staff #3 (S3). Neither P1, S1, nor S2 observed any skin tear, mark, or bruise on R1’s head or body. S2 then escorted R1 back to their apartment/room. According to P1, they phoned R1 around 8:30 PM, at which time R1 told P1 they had a headache for which they would take a Tylenol. Neither P1 nor R1 mentioned R1’s headache to facility staff. 

Interviews of multiple facility staff and P1 aligned to show that R1 seemed normal over the next several days; R1 ate their meals in the dining room and act/spoke as usual. Per interview of P1: They spoke to R1 via phone on 03/27/2025, telling CCLD that R1 sounded “fine” that day. Then on 03/28/2025, P1 transported/escorted R1 to run errands outside the facility, and for the first time P1 noticed a change/decline in R1; specifically, P1 witnessed R1 struggle with separating their personal checks from the carbon copies, which was unlike R1. P1’s observation was communicated to facility staff the next day on 03/29/2025. Upon receiving this information, facility medication technician Staff #4 (S4) and nurse manager Staff #5 (S5) went to observe R1, finding that R1 was alert and speaking, but also confused compared to their baseline. Facility mediation technician Staff #6 (S6) measured R1’s blood pressure at this time, finding it abnormally high at 251/102. Staff arranged for R1 to be transported to a local hospital emergency room (ER) via ambulance. 
Hospital ER records showed: The first computed tomography (CT) scan conducted of R1’s head on 03/29/2025 showed “no acute findings” and “no traumatic findings.” The following day, R1 experienced a stroke around 8:00 PM on 03/30/2025; this was the first time during this hospitalization that R1 was diagnosed with “Acute Stroke,” after which point R1 was transferred to the hospital’s intensive care unit and put on ventilator support. According to their official death certificate, R1’s immediate cause of death was “Acute Respiratory Failure,” secondary to “Nontraumatic Cerebral Intraventricular Hemorrhage” and “Hypertensive Emergency.” There was no involvement from the San Diego County Medical Examiner’s office in this case. 
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20250530085015
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: 06/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/17/2026
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights… (a)… residents… shall have… the following… rights: (8) To be free from neglect…


This requirement was not met as evidenced by:
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Licensee agreed to conduct an in-service retraining for all current staff on Licensee’s operative “Fall Management Protocol” (aka “Policy: 213”) and “Change of Condition Reporting” (aka “Policy: 301”) documents. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date.

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Based on interview and record review, the licensee did not provide medical attention for one resident (R1) after a fall as required by facility policy, which resulted in delayed medical care for their serious illness/injury. This posed an immediate health, safety and personal rights risk to 1 of 122 residents in care.
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This is an amended version of an LIC 9099(d) originally delivered on 6/16/2026
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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: Robyn Clark
LICENSING EVALUATOR NAME: Jose DeLaCruz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7