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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006435
Report Date: 07/03/2025
Date Signed: 07/03/2025 01:42:08 PM

Document Has Been Signed on 07/03/2025 01:42 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 AT TUSTINFACILITY NUMBER:
306006435
ADMINISTRATOR/
DIRECTOR:		LOUER, SANDRA ACOSTAFACILITY TYPE:
740
ADDRESS:12291 S. NEWPORT AVE.TELEPHONE:
(714) 544-5959
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 70CENSUS: 48DATE:
07/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Executive Director Sandra Acosta LouerTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On July 3, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Sandra Acosta Louer later arrived to assist LPA with the inspection. LPA observed that Sandra Acosta Louer has a valid Administrator certificate which expires on January 12, 2026

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for seventy residents, of which seventy can be non-ambulatory, eight can be bedridden, and has a hospice waiver for fifteen. The facility is a one story commercial building comprised of fifty three apartments, forty two of which are on the assisted living side and eleven of which are in memory care. The facility also consist of common areas such as dining rooms in both the assisted living and memory care, activity areas, a commercial kitchen, and staff offices. LPA, accompanied by the ED, conducted a tour of the interior portions of the facility. On today's visit, there are forty eight resident in care. LPA observed residents eating lunch in the dining rooms which consisted of food of their choice. LPA also observed residents returning from a scheduling outing off site. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected seven resident bedrooms located throughout the facility and observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA tested the call buttons in resident bedrooms and they tested operational. LPA inspected the resident bathrooms in the apartments inspected and observed them to be clean. LPA observed resident bathrooms to be equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 108 to 114 degrees Fahrenheit. CONTINUED ON 809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 TUSTIN
FACILITY NUMBER: 306006435
VISIT DATE: 07/03/2025
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LPA inspected the facility kitchen area and observed it be clean. LPA observed the facility to have a minimum two day perishable and seven day non-perishable food supply on hand. LPA observed the facility has a three day emergency food and water supply kept in a storage room. LPA observed multiple fire extinguishers to be mounted in the wall across the facility. All fire extinguishers were observed to be charged and serviced as of October 8, 2024. LPA observed that the facility had their most recent Fire Inspection conducted on March 21, 2025. LPA observed that the facility fire sprinklers and smoke detectors tested operational during the inspection. LPA observed the facility conducted their last emergency disaster drill on May 8, 2025. LPA observed the centrally stored medication to be kept in locked medicine carts located in the medication room. LPA observed First Aid Kits in the medication room and they had all the required components. LPA observed all the facility's chemicals and toxins to be stored in a locked storage room. LPA observed other common areas such as the dining rooms, staff offices, and activity areas to be clear of any hazards.

LPA, accompanied by the ED, conducted a tour of the exterior portions of the facility. LPA observed the facility has outdoor areas for both assisted living and memory care. LPA observed the exterior to be free of obstructions and hazards. LPA observed shaded outdoor seating areas with furniture for resident use. LPA tested the delay egress doors located on the exterior portions which tested operational. There are no bodies of water on the premises.

LPA reviewed the seven resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed residents' medication and medication records. LPA reviewed seven staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Executive Director Sandra Acosta Louer and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
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