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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006223
Report Date: 12/06/2024
Date Signed: 12/06/2024 04:54:03 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
09/18/2024 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240918134343
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: 144DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Executive Director Jennifer TurgeonTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff did not seek timely medical attention for resident
INVESTIGATION FINDINGS:
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On December 6, 2024, Licensing program Analyst (LPA) Jenifer Tirre met with Executive Director (ED) Jennifer Turgeon to deliver findings for the above allegation. The investigation consisted of observations, interviews, and record review. The investigation revealed the following:
Regarding allegation Facility Staff did not seek timely medical attention for resident:
On September 18, 2024, the Department received an allegation that facility staff did not seek timely medical attention for resident.
During the course of this investigation, LPA Tirre conducted an unannounced initial visit on September 23, 2024, and subsequent visits on November 8, 2024, November 26, 2024, and November 27, 2024 related to complaint investigation.
On September 12, 2024, per Call Device Activity Report, resident 1 (R1) pressed their medical alert pendant at 1:09 PM. Caregiver responded at 1:21 PM, twelve (12) minutes after the call. R1 asked for their blood pressure to be checked after they did their own blood pressure reading measuring at 63/39.
CONTINUED ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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 7
Control Number 22-AS-20240918134343
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: 12/06/2024
NARRATIVE
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. Per facility policy, caregivers are not trained to check blood pressure, therefore the caregiver called a Medication Technician (Med Tech). Resident did not want a Med Tech and asked for a Wellness Nurse. In the time while waiting for Wellness Nurse to respond, R1 called 911 themself. Med Tech and Wellness Nurse responded at 1:35 PM just before EMT arrival. Med Tech measured R1’s blood pressure at 95/50. EMT registered two readings, the first at 109/60 pulse 79 and second at 116/63 pulse 79. R1 felt dizzy & clammy and was transported to the hospital. Per R1’s Hospital After Summary Report, resident was diagnosed with Pneumonia, COPD Exacerbation, Gerd, CAR, history of lung cancer and Iron deficiency anemia. On September 13, 2024, resident was discharged back to facility.

Interview with R1 stated that on September 12, 2024, when R1 pressed their medical alert pendant, they claimed it took 20 minutes for staff to respond. R1 claims that a female caregiver arrived at room and didn’t seem to know what to do, R1 asked for a nurse and caregiver to step out of room. R1 stated it took another 15 minutes for Med Tech to arrive.

LPA conducted Interviews with residents and staff and the following was revealed, five (5) of nine (9) residents stated that they don’t use facility pull cord/ call buttons for assistance. Four (4) of nine (9) residents stated they have used pull cords/ call buttons for assistance and stated the average response time is between 10 to 15 minutes.

During investigation, LPA made the following observations when pulling call button in Resident 3’s bedroom to test facility response time and observed staff responded to call eight minutes later. LPA pulled call cord in common area restroom located on first floor and staff responded in seven minutes.

Based on observations, interviews, and record review, it took the facility staff 26 minutes to address residents’ concerns, therefore the preponderance of evidence has been met, therefore the allegations, “Facility staff did not seek timely medical attention for resident” is deemed SUBSTANTIATED. The following is being cited on attached LIC 9099D.

An exit interview was conducted with Executive Director and copies of this report along with Appeals Rights was provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Citations on this Visit Report are Under Appeal!

Control Number 22-AS-20240918134343
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: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
12/07/2024
Section Cited
CCR
87465(g)
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87465 Incidental medical and dental care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by:
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Executive Director agree to meet residents calls in a timely manner. Executive Director agreed to provide a written plan regarding training with all staff regarding pull cords and pendants. ED will send over plan by POC date 12/09/2024. Completed proof of training to be provided one week by 12/13/2024
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Based on the investigation, it took facility staff 26 minutes overall to respond to resident’s medical pendant call failing to address their concerns in a timely manner. R1 called 911 themself and was taken to hospital. This poses an immediate health and safety risk for 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
09/18/2024 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240918134343

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: DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Executive Director Jennifer TurgeonTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff did not follow physician's orders
INVESTIGATION FINDINGS:
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On December 6, 2024, Licensing program Analyst (LPA) Jenifer Tirre met with Executive Director Jennifer Turgeon to deliver findings for the above allegation. The investigation consisted of observations, interviews, and record review. The investigation revealed the following:
Regarding allegation Facility staff did not follow Physician’s orders:
On September 18, 2024, the Department received an allegation that facility staff did not follow Physician’s orders:
During this investigation, LPA Tirre conducted an unannounced initial visit on September 23, 2024, and subsequent visits November 8, 2024, November 26, 2024, and November 27, 2024, related to complaint investigation:
During investigation, LPA conducted interviews with fourteen (14) staff and the following was revealed:
R1 stated they had Endoscopy procedure and staff did not conduct checks on resident after procedure. R1 stated that they received an order from Physician and gave that order to ED Jennifer Turgeon.
CONTINUED ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20240918134343
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: 12/06/2024
NARRATIVE
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R1 did not make a copy of order as they thought it was not needed. ED stated no physician’s order was received. Per interviews with eight (8) out of (14) fourteen staff, residents have status checks done every 2 hours when resident has change in condition, returning from hospital or if resident is a fall risk.

LPA conducted a record review regarding R1’s special orders, during initial visit on September 23, 2024. LPA did not observe any physician’s orders inside R1’s medical file regarding follow up regarding procedure. LPA observed R1’s Hospital After Visit Summary dated September 12, 2024, to September 13, 2024, which stated reason for R1’s visit, list of medications to be picked up, referrals to Transitional Medical clinic & Home Health Outpatient and follow up with internal medicine physician.

LPA observed facility charting notes dated from September 12, 2024, to September 16, 2024 which states the following: on September 13, 2024, R1 returned to the facility at 4:00 PM, alert charting was conducted same day by staff member at 9:02 PM; on September 14, 2024, R1 was checked on twice at 1:38 PM and 9:47 PM; and on September 15, 2024 R1 was checked on twice at 2:49 PM and 9:55 PM.

Based on the information provided for the investigation, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation, “Facility staff did not follow physician’s orders”, did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
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
09/18/2024 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240918134343

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: DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Executive Director Jennifer TurgeonTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff did not provide quality meals
INVESTIGATION FINDINGS:
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On December 6, 2024, Licensing program Analyst (LPA) Jenifer Tirre met with Executive Director Jennifer Turgeon to deliver findings for the above allegation. The investigation consisted of observations, interviews, and record review. The investigation revealed the following:
Regarding allegation Facility staff did not provide quality meals:
On September 18, 2024, the Department received an allegation that facility staff did not provide quality meals.
During this investigation, LPA Tirre conducted an unannounced initial visit on September 23, 2024, and subsequent visits on November 8, 2024, November 26, 2024, and November 27, 2024, related to complaint investigation.
During investigation, LPA made the following observations regarding meals at facility. Facility has adequate supplies of two-day perishables and seven-day nonperishables inside facility kitchen. LPA did not observe spoiled food during visit.
CONTINUED ON 9099C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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 7
Control Number 22-AS-20240918134343
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: 12/06/2024
NARRATIVE
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 LPA observed the facility’s total daily diet is of quality and quantity necessary to meet the needs of the residents and facility is following the Regulatory Standard. LPA observed facility menu located near entrance of dining area. LPA reviewed the facility’s Everyday Menu which has customized meal options available every day.

Menu has options for breakfast, lunch & dinner. Menu shows options for entrees with choice of proteins, sides and sauces for resident’s choosing. The facility offers different types of seafoods such as Swai, Shrimp, Pollock, Crab, Tuna, Salmon, and Cod. Facility has options of sauces available for base of foods such as Marinara sauce, Marsala sauce, Lemon Butter sauce, Alfredo sauce and Mushroom gravy. Per Facility Health Services Policies & Procedures, residents are provided with choices at mealtimes and modified diet standards are available such as No Added Salt, Consistent Carbohydrate, and modified texture. Facility has dietician available to meet with residents as needed.

LPA conducted interviews with nine residents (R1-R9) regarding meals. Eight (8) of nine (9) residents stated food is good and they like the food provided. Resident interviews also mentioned that there’s a variety of choices and residents can order what they wish. One (1) resident alleges that meals have too much salt and they serve low quality fish such as catfish and tilapia. Facility Cook explained per facility policy, food is cooked with no salt and no concentrated sweets.

This agency has investigated the complaint alleging “Facility staff did not provide quality meals”. We have found that the complaint was UNFOUNDED, meaning the allegation was false, could not have happened and or is without a reasonable basis.

An exit interview was conducted with Executive Director Jennifer Turgeon and copy of this report was provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7