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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006222
Report Date: 10/01/2024
Date Signed: 10/01/2024 03:28:08 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/04/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240904100619
FACILITY NAME:IVY AT WELLINGTON, THEFACILITY NUMBER:
306006222
ADMINISTRATOR:OLSON, KATHLEENFACILITY TYPE:
740
ADDRESS:24903 MOULTON PARKWAYTELEPHONE:
(949) 458-2311
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92653
CAPACITY:305CENSUS: 118DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gerry VadnaisTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff do not provide adequate care and supervision for a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that staff do not provide adequate care and supervision for a resident, the investigation revealed the following: Resident 1 (R1) was hospitalized from 09/02/2024-09/09/2024 for weeping legs. Facility conducted an assessment upon return from the hospital with two changes from prior assessment dated 06/15/2024 which includes meal delivery and standby assistance with dressing until the resident recuperates. Resident's physician reports dated 04/23/2019 and 09/09/2024 are virtually the same indicating resident is able to leave the facility unassisted and receives medication management and assistance with bathing. Per interview with resident, resident is independent and able to manage ADL's except bathing assistance. Based on interviews conducted and record review, CONTINUED ON LIC 9099C DATED 10/01/2024
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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 2
Control Number 22-AS-20240904100619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 AT WELLINGTON, THE
FACILITY NUMBER: 306006222
VISIT DATE: 10/01/2024
NARRATIVE
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the allegation is deemed unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2