306006222-12-4-2024-22-AS-MSTC-DCA4AH-20241224175558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006222
Report Date: 12/04/2024
Date Signed: 12/04/2024 09:18:31 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
11/04/2024 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241104110548

FACILITY NAME:	IVY AT WELLINGTON, THE		FACILITY NUMBER:	306006222
ADMINISTRATOR:	VADNAIS, GERRY		FACILITY TYPE:	740
ADDRESS:	24903 MOULTON PARKWAY		TELEPHONE:	(949) 458-2311
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	305	CENSUS: 116	DATE:	12/04/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Gerry Vadnais		TIME COMPLETED:	09:35 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained multiple unexplained bruises while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

This unannounced visit conducted by Licensing Program Analysts (LPA) Ruth Martinez is being conducted to conclude this agency’s investigation into the complaint allegation mentioned above.

During the course of the investigation the following was conducted: interviews were conducted with staff, interviews were conducted with resident, a tour of the resident’s bedroom was conducted, a review of resident records was completed and copy of pertinent documents obtained.

It is alleged resident sustained multiple unexplained bruises while in care. Interviews were conducted with staff which indicated that resident (R1) was being treated for Edema of the lower leg and for her ASCVD (Atherosclerotic cardiovascular disease) by a home health agency. R1 was sent to hospital on October

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion: 30

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

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-20241104110548

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: IVY AT WELLINGTON, THE	FACILITY NUMBER: 306006222
	VISIT DATE: 12/04/2024

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

30, 2024, due to general weakness and level of consciousness. Staff indicated that due to the Edema R1’s legs can get bruising as well R1 is on blood thinner medication that can play a big role in bruising easily. On November 13, 2024, LPA Martinez inspected R1’s apartment and observed R1 in their apartment in bed. LPA observed R1’s physical appearance and did not observe any bruising in R1’s arms, R1 in conversation showed LPA R1’s legs and LPA observe legs to have bandages due to R1’s Edema care but did not observe to have any bruising at the time of visit.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with Administrator and a copy of this LIC9099 report was left at facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2