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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006233
Report Date: 02/19/2025
Date Signed: 02/19/2025 01:08:02 PM

Document Has Been Signed on 02/19/2025 01:08 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:IVY PARK OF WELLINGTONFACILITY NUMBER:
306006233
ADMINISTRATOR/
DIRECTOR:
DAVID ARMOURFACILITY TYPE:
740
ADDRESS:24962 CALLE ARAGONTELEPHONE:
(562) 865-9500
CITY:LAGUNA WOODSSTATE: CAZIP CODE:
92637
CAPACITY: 220CENSUS: 166DATE:
02/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:David Armour, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on an incident reported to CCLD on February 05, 2025. LPA met with David Armour, Administrator/Executive Director and explained the purpose of today’s visit. Incidents was self reported on February 4, 2025 via incident report telephone call and LIC624 was received on February 05, 2025 regarding residents (R1) incidents of February 04, 2025.

During today’s visit, LPA interviewed staff and obtained copies of pertinent documents.

On February 04, 2025, at approximately 3:15am R1 left the premises via kitchen loading dock and headed towards the street. A civilian saw R1 and called 911 to report and paramedics were sent out. R1 was take to hospital for evaluation and has not returned to the community. Facility received a call from the hospital about 4:15AM informing them that R1 was at the hospital. R1 was discharged to a skilled nursing and facility staff is to re-assessed R1 prior to returning to the community. Once facility received call from the hospital informing them that R1 was there, facility staff called responsible party, Executive Director and LPA Martinez to informed them on the incident. This visit is being conducted for the purpose to review incident details and collect facility records. Facility has been in contact with hospital, skilled nursing and R1's DPOA for updated information. LPA did not observe any immediate and/or safety risks in or out of the facility.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Executive Director and a copy of the report was provided and left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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