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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604455
Report Date: 02/24/2023
Date Signed: 02/24/2023 12:13:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/15/2022 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20221115153927
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:
02/24/2023
UNANNOUNCEDTIME BEGAN:
10:44 AM
MET WITH:Angela Scott KaplioffTIME COMPLETED:
12:34 PM
ALLEGATION(S):
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Staff did not distribute residents' medications as prescribed
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 Angela ScottKaplioff 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 reported to CCL that staff did not distribute medications to Resident 1 (R1) and Resident 2 [an LIC 811 Confidential Names List was provided to the facility representative to identify the residents.] and it was also reported that staff distributed discontinued medications to residents. Records review revealed the facility’s Medication Administration Records (MARs) for R1 indicated R1 was receiving medications as prescribed, by staff daily initialing the MARs as dispensed for the month of November 2022.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
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
Control Number 08-AS-20221115153927
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/24/2023
NARRATIVE
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Records review also revealed the facility’s Medication Administration Records (MARs) for R2 indicated R2 was receiving medications as prescribed, by staff daily initialing the MARs as dispensed for the month of November 2022.

Interview with facility staff revealed an internal facility investigation was conducted. The medication for R1 and R2 was counted and compared for; morning, evening and bedtime and all of the medications had the same, correct amount. It was determined that the medications were "popped" on different dates which is why it was believed that the medications were not distributed to R1 and R2. Interview with facility staff further revealed that discontinued medication for Resident 3 (R3) was stored in the same drawer with the "active" medications. As a result, the discontinued medication was distributed to R3 on November 2, 2022. Staff noticed the handwritten note on the medication bottle indicating it was discontinued after dispersing to resident.

Interview with Executive Director revealed R1 and R2 were given all of their medications by facility staff. The medications were given from the "new card of medications" as opposed to the last of the medication from the "ending card." Executive Director further stated that medications are received in a monthly cycle, so the medication was dispersed from the upcoming month. Executive Director stated that R3's doctor was notified (on November 2, 2022) of the resident receiving the discontinued medication in error. Records review revealed R3 was placed on 72 hours alert charting on November 2, 2022.

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 allegations are valid. Deficiencies are cited in accordance with California Code of Regulations, Title 22 and are noted on the attached LIC 9099-D.

An exit interview was conducted with Angela Scott Kaplioff and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Angela Scott Kaplioff whose signature below confirms receipt of documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20221115153927
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2023
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care Services. Once ordered by the physician...medications shall be given in accordance with the physician’s directions. This requirement was not met as evidenced by:
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Per Licensee, medication error prevention training was attended by med tech staff on various dates in the month of November 2022. LPA was given a copy of the training agenda and attendance roster on 2/24/23
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Based on staff interview the licensee did not give medications in accordance with the physician's directions.1 in 1 of [85] persons in care (R1) which posed a potential health risk to persons in care.




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This is an amended version of the original report created on 2/24/23



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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: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/15/2022 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20221115153927

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:
02/24/2023
UNANNOUNCEDTIME BEGAN:
10:44 AM
MET WITH:Angela Scott KapiloffTIME COMPLETED:
12:34 PM
ALLEGATION(S):
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Staff did not properly supervise resident
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 Angela Scott Kaplioff 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 direct observation, records review and interviews with facility staff and residents.

It was reported to CCL that staff did not properly supervise Resident 4 (R4) [an LIC 811 Confidential Names List was provided to the facility representative to identify the residents.]Resulting in R4 exiting the facility. Interview with facility staff revealed R4 lives in the memory care unit and is checked out of memory care every morning by R4's spouse Resident 5 (R5) who lives in the assisted living section of the facility. Staff further revealed that alarms would sound both in the memory care unit and in the assisted living section if R4 exited the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20221115153927
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/24/2023
NARRATIVE
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Furthermore staff stated that it takes approximately 2-3 minutes for the alarm to be reset and all staff would be aware of any resident elopement.

Interview with R4's spouse R5 revealed they have both lived at the facility since November 2021 and R4 is never out alone in the facility. R5 further stated that R4 has never exited the facility alone and R5 knows this for a fact since R4 is always with R5 when R4 leaves the memory care unit.

Interview with Executive Director revealed R4 is always monitored by front desk staff when out of the memory care unit.

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 Angela Scott Kaplioff and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Angela Scott Kaplioff whose signature below confirms receipt of documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5