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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604455
Report Date: 04/03/2026
Date Signed: 04/03/2026 11:40:15 AM

Document Has Been Signed on 04/03/2026 11:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 RANCHFACILITY NUMBER:
374604455
ADMINISTRATOR/
DIRECTOR:
CALAIS ANGUIANOFACILITY TYPE:
740
ADDRESS:1290 SANTA ROSE DRIVETELEPHONE:
(619) 779-7400
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 137CENSUS: 122DATE:
04/03/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Executive Director Diana WeinsteinTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Diana Weinstein.

CCR 87466 states, “The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning…” Per Licensee’s “Fall Management Protocol” written policy, all falls, witnessed or unwitnessed, “will require completion of an Unusual Occurrence Report and an investigation of the circumstances leading to the fall,” and “any resident sustaining a fall will also be placed on Alert charting status.” The policy further states that an “internal Incident Report (Form 406a) is completed every time a resident falls,” and the “the [resident's] healthcare practitioner will be notified using Form 213a, Physician Fax Report of Fall.”

Review of records and interviews of staff and outside sources showed: Resident #1 (R1) fell just outside the facility’s main entrance door on 03/22/2025. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] The responding facility staff, Staff #1 (S1) and Staff #2 (S2), did not timely inform any medication tech, nurse, or manager about this fall. No internal Incident Report (Form 406a) was completed for this fall around when it occurred. Also, Licensee did not timely submit an LIC624 Unusual Incident/Injury Report to CCLD for this fall (this latter element was already addressed/cited in a separate complaint report). R1’s primary care physician (i.e., the pertinent healthcare provider) was also not timely notified of R1’s fall via a Form 213a, or by any other means. [CONTINUED ON LIC 809-C, 1 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2026
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: IVY PARK AT OTAY RANCH
FACILITY NUMBER: 374604455
VISIT DATE: 04/03/2026
NARRATIVE
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[CONTINUED FROM LIC 809] During his own 06/02/2025 site visit, LPA requested from Licensee copies of the facility staff’s charting and/or progress notes, which would evidence that “Alert charting” was performed on R1 post-fall. However, facility managers replied that no such notes existed which could prove that R1 was placed on “Alert charting status,” as was required by Licensee’s own written policy. As confirmed in administrator interview, Licensee defined “Alert charting” as the facility’s licensed nurse meeting with the resident face-to-face daily, for at least three (3) consecutive days after the fall, to assess the resident’s health and ask about their experienced symptoms, and to document these findings in electronic progress notes. “Alert charting” is therefore more than a cursory observation of the resident in passing, by lay staff.]

Staff interviews showed: By 03/29/2025, Staff #4 (S4), the facility medication technician who called/arranged an ambulance for R1’s confusion and elevated blood pressure, was still unaware that R1 had fallen a week earlier. Likewise, the nurse manager then overseeing the facility’s clinical operations, Staff #5 (S5), and their deputy supervisor, Staff #7 (S7), both did not become aware that R1 had fallen a week earlier, until after R1 was already at the hospital. While there is no regulation specifically addressing internal communication, the failure of staff to internally communicate in this instance evidenced Licensee falling short of its own policy/procedural requirements regarding post-fall observation of R1. (In the final analysis, CCLD’s investigation showed that R1’s fall was not a proximate cause of R1’s confusion or elevated blood pressure. However, S4, S5, and S6 each affirmed to LPA that knowing about a prior fall provides useful context needed to inform subsequent observation checks and incidental medical care decisions, and that S1 and S2 should have reported the fall per protocol, when it occurred.)

Additionally, during an earlier 06/23/2025 site visit, a California Department of Social Services (CDSS) Investigator (a peace officer acting in an official capacity on behalf of CCLD) formally requested from facility manager S5 a copy of the surveillance camera video footage segment depicting R1’s aforementioned fall on 03/22/2025. As of the date of this 06/23/2025 request, the pertinent footage was still intact and viewable, as witnessed by the Investigator. The Investigator made multiple follow-up phone calls to S5 for a copy of this footage for CCLD’s case file, but it was not provided to the Department. The Investigator subsequently spoke to the new facility administrator on 10/03/2025, who reported that as of that date, the pertinent footage no longer existed. [CONTINUED ON LIC 809-C, 2 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
LIC809 (FAS) - (06/04)
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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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: IVY PARK AT OTAY RANCH
FACILITY NUMBER: 374604455
VISIT DATE: 04/03/2026
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

Two (2) deficiencies were cited according to California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/03/2026 11:40 AM - It Cannot Be Edited


Created By: Dang Nguyen On 04/03/2026 at 11:05 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2026
Section Cited
CCR
87466

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87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning…” This requirement was not met, as evidenced by:
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Licensee agreed to conduct an in-service retraining for all current staff on Licensee’s operative “Fall Management Protocol” (aka “Policy: 213”) and “Change of Condition Reporting” (aka “Policy: 301”) documents. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date.
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Based on records and interviews, Licensee did not ensure that 1 of 113 residents (R1) was regularly observed for changes in physical, mental, emotional and social functioning following their fall. This posed a potential health risk to persons in care.
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Type B
04/03/2026
Section Cited
CCR87755(c)

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87755 Inspection Authority of the Licensing Agency: “(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours.” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, CCLD completed its investigation of R1’s fall without a preserved recording of the pertinent footage. LPA advised the facility administrator to consult with whomever is needed to learn / better understand the technical features of their video surveillance system, such that preserving future recording excerpts is done easily. Licensee was advised that repeat violations may incur a civil penalty and/or trigger a Non-Compliance Conference (NCC).
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Based on records and interviews, Licensee did not cooperate with the licensing agency’s authority to receive a copy of a facility recording pertaining to an investigation involving 1 of 113 residents (R1). 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2026


LIC809 (FAS) - (06/04)
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