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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604455
Report Date: 11/14/2025
Date Signed: 11/14/2025 02:45:26 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
09/12/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 08-AS-20240912160901
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: 119DATE:
11/14/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Stacey Dickmann, Health Service DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Neglect resulting in serious bodily injury
INVESTIGATION FINDINGS:
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On 11/14/2025 at 02:30 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger meet virtually via Teams to deliver findings for the above allegations. LPA explained the purpose of the visit with Health Service Director, Stacey Dickmann.

The Department conducted a tour of the facility, interviewed residents and staff members who may have witnessed or had relevant information regarding the incidents, and reviewed relevant documentation, including resident care plans, incident reports, and other relevant records.

On the allegation: Neglect resulting in serious bodily injury

On 9/11/2024 R1 fell in the activity room and attempted to leave the facility on their own without waiting for assistance. Staff was nearby to assist R1 and R1 was immediately taken to the hospital to be evaluated.
Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
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 2
Control Number 08-AS-20240912160901
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: IVY PARK AT OTAY RANCH
FACILITY NUMBER: 374604455
VISIT DATE: 11/14/2025
NARRATIVE
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...Continued from LIC9099

Based on the statements provided by staff present during R1’s fall on 9/11/2024, there would have been little they could do to prevent R1 from falling. R1 had been on fall precautions since April of 2024, and R1 is assisted to and from bed by staff and taken into the community during the day for more supervision. R1 receives frequent checks while in her room during the evening hours. R1 was also provided a fall mat alongside their bed, and their bed was lowered to its lowest position.

Based on the above information. The allegation of Neglect/Lack of Care and Supervision of R1 suffering a fall and sustaining serious bodily injury will be Unsubstantiated. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2