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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006764
Report Date: 11/18/2025
Date Signed: 11/20/2025 01:19:41 PM

Document Has Been Signed on 11/20/2025 01:19 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 TERRACE AT SANTA ANAFACILITY NUMBER:
306006764
ADMINISTRATOR/
DIRECTOR:		TORRES, JUDITHFACILITY TYPE:
740
ADDRESS:3730 S. GREENVILLE STREETTELEPHONE:
(714) 641-0959
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY: 72CENSUS: 46DATE:
11/18/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:36 PM
MET WITH:Applicant Judith TorresTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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On November 18, 2025, Licensing Program Analyst (LPA) Garlli Tat conducted an announced pre-licensing visit to the facility and was greeted and granted entry by applicant Judith Torres. LPA observed the Administrator's Certificate expires on July 15, 2026 and is posted at the lobby and office. The Department received an application for a Change of Ownership for the Residential Facility for the Elderly (RCFE) on October 30, 2025.
LPA toured the exterior and interior portion of the facility with the applicant.

Structure: Facility is a single level structure. On April 10, 2025, The Orange County Fire Authority granted fire clearance for a capacity of 72 residents (68 of which may be non-ambulatory, four may be bedridden, and hospice waiver for 15) on August 28, 2025. There are a total of 36 bedrooms. There is a current census of 46 residents.

Bedrooms: All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept hazard free.

Bathrooms: The bathrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in bathrooms were measured to be at 110 degrees Fahrenheit.

Linens and Hygiene Supplies: Adequate supply of linens is stored in the storage room.

Posters, Emergency Phone Numbers, Exit Plan: LPA observed the PUB475 "See Something, Say Something" poster posted at the front lobby and dining room. Emergency disaster plan is posted in the lobby. Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2025
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 TERRACE AT SANTA ANA
FACILITY NUMBER: 306006764
VISIT DATE: 11/18/2025
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Food Service and Menu: Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Facility had back-up emergency food and water supply located in the storage room.

Smoke and Carbon Monoxide Detectors: Smoke and carbon monoxide alarms have been tested on April 10, 2025.

Fire Extinguisher: Fire extinguishers were fully charged, and mounted in the hallways, and tagged for the date of April 10, 2025. Fire sprinklers were also tested on this date.

Appliances: The kitchen is fully equipped with a stove, oven, dishwasher, refrigerator and freezer. Washer and dryer are located in the laundry room.

Toxins: Toxins are locked and inaccessible to residents in a storage room.

Medications, PPE First-Aid Kit and Manual: LPA observed the First Aid kit located in the medication room and had all the required components. Medications were locked in the medication room.

Backyard: No bodies of water were observed. The outdoor area is free of hazards and there are seating areas under shade. The exterior doors are secured for resident safety.

Resident and Staff Files: Records were kept locked in the Executive Director's office and in the medication room.

Recreational Activities: The facility has a schedule of daily activities and a daily menu posted in the dining room.



LPA reviewed the Component III presentation with the applicant Judith Torres.

The applicant has met all pre-licensing requirements. LPA will submit notification to Centralized Applications Bureau (CAB) for final review prior to license being issued.

LPA conducted an exit interview with applicant Judith Torres and a copy of this report was reviewed and provided to the facility
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Garlli Tat
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC809 (FAS) - (06/04)
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