<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003766
Report Date: 09/27/2023
Date Signed: 09/27/2023 03:28:02 PM

Document Has Been Signed on 09/27/2023 03:28 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:
09/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Carmen RodriguezTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 Edy ”Janet" Santiago and explained the purpose of the visit. Administrator (AD) Carmen Rodriguez was contacted by phone and arrived at 2:20 p.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.

LPA interviewed S1 who stated S3 had been causing injuries to residents while assisting them with Activities of Daily Living (ADLs). S2 was also interviewed and corroborated S3 had been causing injuries to residents. LPA interviewed six out of six facility residents. Four out of six were unable to confirm or deny if staff has caused them injury while assisting them. Two out of six residents denied being injured by staff intentionally or otherwise. LPA interviewed two additional staff, who denied ever witnessing S3 causing physical harm or injury to residents. LPA interviewed S3 who denied ever causing physical harm or injury to residents.

During today's inspection, LPA interviewed AD, who denied ever witnessing S3 causing physical harm or injury to residents. LPA presented AD with pictures obtained of residents with discoloration to one resident's lip, and a skin tear from the top of one resident's arm to their elbow with discoloration encompassing most of the bottom of the arm. AD confirmed the injuries were of current and past residents and stated the injuries had been self-inflicted, however, none of these incidents were reported to the Department; a Deficiency is being cited on today's date.

Due to conflicting information received during interviews conducted with facility staff and residents, LPA is unable to determine if S3 has caused physical harm or injury to residents, and there is not a preponderance of evidence to prove S3 did cause physical harm or injury to residents. No further action is required..

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 306003766
VISIT DATE: 09/27/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on observations made during today's inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/27/2023 03:28 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/27/2023 at 03:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY COTTAGES II
FACILITY NUMBER: 306003766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
CCR
87211(a)

1
2
3
4
5
6
7
(1) A written report shall be submitted to the licensing agency... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.

This requirement is not met as evidence by;
1
2
3
4
5
6
7
AD stated they will submit an incident report for any and all incidents occuring at the facility. AD will provide LPA with a signed copy of regulation reviewed by POC date.
8
9
10
11
12
13
14
During interivews, AD confirmed of at least two incidents when a resident sustained an injury under facility supervision and AD did not sumbit a written report to the Department.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3