374604747-5-22-2025-08-AS-APAO-DH5PYH-20250529114359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604747
Report Date: 05/22/2025
Date Signed: 05/22/2025 11:03:54 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
12/16/2024 and conducted by Evaluator Nacole Patterson

COMPLAINT CONTROL NUMBER: 08-AS-20241216101746

FACILITY NAME:	IVY PARK AT SABRE SPRINGS		FACILITY NUMBER:	374604747
ADMINISTRATOR:	DAYNES, ROBERT		FACILITY TYPE:	740
ADDRESS:	12515 SPRINGHURST DRIVE		TELEPHONE:	(858) 391-9160
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY:	100	CENSUS: 99	DATE:	05/22/2025
		UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Executive Director Rob Daynes		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Staff did not distribute residents' medications as prescribed.
Staff did not ensure that residents' medications were stored in their original container.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes.

On 12/16/2024 it was alleged that staff did not distribute residents' medication as prescribed, and staff did not ensure that residents' medications were stored in their original container. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

Seven (7) staff were interviewed regarding medication administration, six (6) of whom were Med Techs or trained to pass medications. All staff provided consistent information regarding the process for passing medications. No staff had observed or were aware of medication errors that had occurred.
(Continued on LIC9099 p.2)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20241216101746

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 SABRE SPRINGS	FACILITY NUMBER: 374604747
	VISIT DATE: 05/22/2025

NARRATIVE

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(Continued from LIC9099 p.1)

Resident interviews did not corroborate the allegation. One resident that was claimed to have been involved in a medication error stated they had no issues at the facility and that the medication administration was good. Attempts were made to interview the second resident noted to have suffered a medication error, but the resident was unable to be interviewed.

Facility records were reviewed regarding the allegation. Facility training records for Medication Technicians (Med Techs) were consistent with the medication processes listed by the Med Techs during interview. No records were found to show that a medication error had occurred.

Regarding the allegation, "Staff did not ensure that residents' medications are stored in its original container", Staff members consistently stated that they had not observed any staff pre-pour medications. Staff informed that Med Techs actively pour while administering medications, or prepare all medications at once then pass to residents, with the preparation time not exceeding more than 1 hour, per company policy. Staff informed that inconsistencies existed with specific staff regarding the interpretation of what pre-pouring was. The staff member accused of pre-pouring informed that the resident was right in front of them during the medication administration and they were the only resident that was being assisted at the time, there was no confusion with the cups and no pre-pouring occurred.

Review of facility records showed substantial medication training consistent with staff statements regarding how medications were administered at the facility. The facility's medication training policy dated December 2023 stated, "Resident medications may only be poured for a single med pass at a time".

LPA directly observed the medication procedures and medication carts during two unannounced facility visits. LPA did not observe any medication cups that had been prepared in advance, locked or unlocked, around the facility or in the medication cart drawers.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

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