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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604455
Report Date: 06/02/2025
Date Signed: 06/02/2025 06:12:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2025 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20250530085015
FACILITY NAME:IVY PARK AT OTAY RANCHFACILITY NUMBER:
374604455
ADMINISTRATOR:CALAIS ANGUIANOFACILITY TYPE:
740
ADDRESS:1290 SANTA ROSE DRIVETELEPHONE:
(619) 779-7400
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY:137CENSUS: 113DATE:
06/02/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director Calais Anguiano TIME COMPLETED:
06:30 PM
ALLEGATION(S):
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-Licensee did not meet reporting requirements.
-Licensee did not keep resident’s room free of rodent(s).
-Licensee did not provide copy of admissions agreement to resident’s representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Calais Anguiano.

The Complainant alleged that Licensee did not keep meet reporting requirements regarding an incident involving Resident #1 (R1), that Licensee did not keep R1’s room free of rodents, and that Licensee did not provide a copy of R1’s admissions agreement contract to R1’s representative. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The Department’s investigation involved an unannounced facility tour/welfare check, review of pertinent CCLD and facility records, and interviews of relevant staff and outside sources.

[CONTINUED ON LIC 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
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 08-AS-20250530085015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: IVY PARK AT OTAY RANCH
FACILITY NUMBER: 374604455
VISIT DATE: 06/02/2025
NARRATIVE
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[CONTINUED FROM LIC 9099]

Interviews aligned to show: On 03/22/2025, R1 fell on the facility premises, right outside the lobby front door, to which facility staff responded timely. On 03/29/2025, facility staff arranged for R1 to be transported to the hospital for a change in condition, where R1 was admitted. R1 remained at the hospital, where they subsequently died in late April 2025. Licensee did not submit written incident reports to CCLD or R1’s responsible person describing R1’s fall, hospitalization, or death; these were required to be submitted to both parties within seven (7) days of occurrence.

Interviews of a corroborating outside source showed this person found two (2) mice hiding inside a cardboard box inside R1’s bedroom, which they removed and brought outside. CCLD also obtained photographic evidence of rat multiple droppings on R1’s personal effects.

Available records and interviews showed: R1’s and their representative/responsible person (RP) both previously signed an Admissions Agreement which Licensee prepared for R1. However, a facility representative did not co-sign on behalf of Licensee. [Licensee’s missing signature will be addressed in a separate Case Management visit report.] R1’s RP then requested a copy of the contract from Licensee, but Licensee did not follow through on this request.

Based on records and interviews, a preponderance of evidence exists to show Licensee did not meet reporting requirements, that Licensee did not keep resident’s room free of rodents, and that Licensee did not provide copy of admissions agreement to resident’s representative. These allegations were Substantiated, and three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Anguiano, to whom a copy of this report, the LIC 9099-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20250530085015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: IVY PARK AT OTAY RANCH
FACILITY NUMBER: 374604455
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2025
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements: “(a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…(D) Any incident which threatens the welfare, safety or health of any resident…” This requirement was not met, as evidenced by:
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Licensee agreed to submit write and submit one (1) LIC624 Incident Report (to cover both R1’s fall and hospitalization) and one (1) LIC624A Death Report (to cover the extent of what Licensee knows about R1’s death, as reported by their RP). Licensee agreed to E-mail copies of the LIC624 and LIC624A to the Department (CCLASCPSanDiegoRO@dss.ca.gov, Cc’ing LPA Nguyen) and to R1’s RP, by the POC due date.
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Based on records and interviews, Licensee did not submit a written report to the licensing agency and to the person responsible for 1 of 113 residents (R1) who had an incident which threatened their welfare, safety, or health. This posed a potential personal rights risk to persons in care.
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Type B
07/02/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: “(a) The facility shall be clean, safe, sanitary…at all times.” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, the mice observed in R1’s room have been removed and the room has been thoroughly cleaned. On 05/09/2025, the facility’s Executive Director and Regional Maintenance Director walked the room, finding no evidence of vermin. Licensee agreed to bring in a professional pest control company to inspect the facility for vermin, to ensure no future problems, and to E-mail a copy of the visit report to LPA, by the POC due date.
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Based on records and interviews, Licensee did not ensure the facility was clean and sanitary at all times. This posed a potential health and safety risk to persons 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20250530085015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: IVY PARK AT OTAY RANCH
FACILITY NUMBER: 374604455
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2025
Section Cited
CCR
87507(e)
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87507 Admission Agreements: “(e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request.” This requirement was not met, as evidenced by:
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Licensee agreed to E-mail a copy of R1’s latest unaltered admissions agreement document to their responsible person (Cc’ing LPA Nguyen), by the POC due date.
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Based on records and interviews, Licensee did not provide copy of the signed and dated current admission agreement to the representative of 1 of 113 residents (R1) immediately upon singing the admission agreement and upon request. This posed a potential personal rights violation to persons 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5