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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003766
Report Date: 09/19/2023
Date Signed: 09/19/2023 02:38:15 PM

Document Has Been Signed on 09/19/2023 02:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:IVY COTTAGES IIFACILITY NUMBER:
306003766
ADMINISTRATOR:CARMEN RODRIGUEZFACILITY TYPE:
740
ADDRESS:16827 MT. EDEN STREETTELEPHONE:
(714) 531-2185
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
09/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Carmen NunezTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced case management visit for the purpose of following-up on an incident report submitted to the Department on 9/07/23. LPA was greeted and granted entry by Staff 1 (S1) Edy ”Janet" Santiago and explained the purpose of the visit. Assistant Administrator (AAD) Carmen Nunez was contacted by phone and arrived at 11:15 a.m.

Incident report indicated that Staff 1 (S1) and Staff 2 (S2) had reported irregularities regarding Staff 3 (S3). An internal investigation was conducted, and no irregularities were found. The decision was made to relocated S3 to a sister facility and no further incidents have been reported.

Upon follow-up, irregularities were found to pertain to residents’ personal rights. LPA interviewed S1 who corroborated incident was a personal rights matter. S2 and S3 were not present to be interviewed. LPA interviewed all six facility residents and two additional staff. LPA obtained copies of Personnel Report (LIC500), staff schedule, and staff contact information. LPA informed AAD that subsequent visits and document requests could be required regarding the incident and AAD stated they understood.

No citation were noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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