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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006223
Report Date: 06/20/2024
Date Signed: 06/20/2024 01:56:25 PM

Substantiated


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
06/17/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240617153724
FACILITY NAME:IVY PARK AT LAGUNA WOODSFACILITY NUMBER:
306006223
ADMINISTRATOR:MADSEN, ELENAFACILITY TYPE:
740
ADDRESS:24441 CALLE SONORATELEPHONE:
(949) 830-8057
CITY:LAGUNA WOODSSTATE: CAZIP CODE:
92637
CAPACITY:233CENSUS: 131DATE:
06/20/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Elena MadsenTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Facility did not accept resident back after hospitalization
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to begin the investigation into the allegations listed above. LPA met with Executive Director Elena Madsen and explained the reason for the visit. The investigation into to the allegation revealed the following. It was alleged that Resident 1 (R1) was not allowed back to the facility after the Skilled Nursing Facility (SNF) cleared R1 to return to their home. R1’s responsible party (RP) reported that they spoke to the Executive Director who informed them R1 would need medication management if they were to return to the facility based on the nurse’s assessment. RP reported that they disagreed with the assessment and provided an LIC 602A dated June 7, 2024, which stated R1 could manage their own meds with the following comments in the comments section, “PT can take own medication in the pillbox sorted by son”. The LIC 602A section 16 concerning resident medication is a yes or no question, the resident is either cable of handling every aspect of managing their own medication or they can’t. In the case of R1 the facility is correct in assessing that R1 needs medication management. The ED had a care plan meeting with RP on June 7, 2024, to discuss R1’s new care plan.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
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 5
Control Number 22-AS-20240617153724
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 PARK AT LAGUNA WOODS
FACILITY NUMBER: 306006223
VISIT DATE: 06/20/2024
NARRATIVE
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This meeting was a conference call and The Regional Health Services Director for the facility was also present. The ED reported that they presented the plan and informed RP that R1 needed medication management and they would have to agree to the new assessment and care plan in order for R1 to return to the facility. RP verified this report. The RP reported that they disagreed with the assessment and did not think R1 needed medication management, but they never received a copy of the care plan, so they didn’t have an opportunity to review the new care plan. RP stated they did not have a chance to approve or reject the care plan. The ED verified they did not send the new care plan to the RP because they were informed, they would not agree to it because it was not needed. The RP verified this report. R1 was cleared to return to the facility on or around June 7, 2024. R1 is currently at a SNF. The facility has taken no action to provide the RP with the new care plan or to contact R1 or RP. Based on the evidence gathered the preponderance of evidence standard has been met; therefore, the above allegation is substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the report along with appeal rights was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/17/2024 and conducted by Evaluator Joseph Alejandre
COMPLAINT CONTROL NUMBER: 22-AS-20240617153724

FACILITY NAME:IVY PARK AT LAGUNA WOODSFACILITY NUMBER:
306006223
ADMINISTRATOR:MADSEN, ELENAFACILITY TYPE:
740
ADDRESS:24441 CALLE SONORATELEPHONE:
(949) 830-8057
CITY:LAGUNA WOODSSTATE: CAZIP CODE:
92637
CAPACITY:233CENSUS: 131DATE:
06/20/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Elena MadsenTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Facility did not issue refund
INVESTIGATION FINDINGS:
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The investigation into the allegation, facility did not issue refund, revealed the following. It was alleged that the facility has not refunded R1’s rent for June 2024. The responsible party for R1 (RP) stated the ED offered a refund for June 2024, so they expect to receive it. The responsible party (RP) reported they did not receive a refund for rent paid for June 2024. RP reported that since R1 is not at the facility and since the facility is not letting R1 return they should receive a refund for June 2024 as offered by The Executive Director (ED). The ED reported that after the care plan meeting for R1 they did not expect R1 to return to the facility. The ED reported that they are processing the refund for June 2024 but as per the admission agreement they have 21 days to provide the refund and R1’s belongings are still in R1’s room. LPA verified that R1’s belongings are still in their room. The facility is not required to provide a refund at this time based on the June 7, starting date and based on the 21 days stated in the admission agreement for providing refunds once the unit is vacated, but the facility has offered a refund and RP did not reject their offer of a refund.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20240617153724
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 PARK AT LAGUNA WOODS
FACILITY NUMBER: 306006223
VISIT DATE: 06/20/2024
NARRATIVE
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Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240617153724
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 PARK AT LAGUNA WOODS
FACILITY NUMBER: 306006223
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2024
Section Cited
CCR
87224(a)
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Eviction Procedures- The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty days written notice to the resident is required...This requirement was not met as evidenced by:
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Licensee agrees to review regulation 87224 Eviction Procedures and provide proof of understanding that a 30 day notice should be issued before a resident is evicted. Licensee to submit proof of understanding to LPA by POC due date of 6/21/2024.
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Based on interviews and file review, the facility did not take R1 back from the Skilled Nursing Facility. The licensee did not serve R1 with a 30 day notice to evict the resident. This poses an immediate Health and Safety and/or Personal Rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5