374604747-3-27-2025-08-AS-LTEZ-DH62B9-20250529171447

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604747
Report Date: 03/27/2025
Date Signed: 03/27/2025 04:33:54 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
07/02/2024 and conducted by Evaluator Nacole Patterson

COMPLAINT CONTROL NUMBER: 08-AS-20240702125951

FACILITY NAME:	IVY PARK AT SABRE SPRINGS		FACILITY NUMBER:	374604747
ADMINISTRATOR:	DAYNES, ROBERT		FACILITY TYPE:	740
ADDRESS:	12515 SPRINGHURST DRIVE		TELEPHONE:	(858) 391-9160
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY:	100	CENSUS: 98	DATE:	03/27/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Executive Director Rob Daynes		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident fall due to neglect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes.

On 07/02/2024 it was alleged that staff neglect led to Resident 1 (R1)'s fall, resulting in R1 lying on the floor throughout the night. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff interviews did not corroborate the allegation, as staff consistently denied that Resident 1 (R1) suffered a fall that resulted in them being unattended for hours without staff help. Staff informed that R1 lived in the Assisted Living section of the building and was mostly independent, not requiring assistance with Activities of Daily Living (ADLs) or checks throughout the night. Staff interviews revealed that R1 began to experience a change in cognition during the timeframe of complaint, experiencing disorientation to time and place, and misremembering events. (Continued on LIC9099 p.2)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240702125951

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 SABRE SPRINGS	FACILITY NUMBER: 374604747
	VISIT DATE: 03/27/2025

NARRATIVE

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(Continued from LIC9099 p.1)

Staff interviews further revealed that R1 slipped from their bed the evening of 06/28/2024 with no injuries, and staff responded to assist them during the event.

An outside advocacy agency familiar with the facility and R1's care was contacted and stated they had no concerns regarding the facility's supervision and care to residents. The outside source remarked that R1 may have been experiencing confusion when they made the statement about lying on the ground. A second outside source informed that R1 presented as independent.

Records review revealed facility pendant and Narrative Charting logs during the timeframe of complaint. The documents showed that R1 pressed their pendant twice during the early morning on 06/28/24, and was responded to within 7 minutes, and then 2 minutes. The 2-minute response time was noted to be when R1 was found sitting on their bedroom floor after slipping from their bed; R1 informed staff that they did not suffer an injury during this incident. Additional facility and outside source records showed that R1 was evaluated to be independent upon moving into the facility and was able to perform all Activities of Daily Living (ADLs) without assistance, including going for walks outside of the facility unassisted. No records were found to establish that R1 required routine nighttime checks, or that staff delayed in responding to R1's pendant call when they requested help.

During an unannounced facility visit LPA interviewed R1. LPA noted that R1 had moved from the Assisted Living section of the building to the Memory Care unit. R1 stated that they did not recall falling and lying on the ground all night without assistance. R1 stated that staff came right away when they pushed their call button and provided great care. R1 informed they loved living at the facility and had no issues with the care provided.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC9099 (FAS) - (06/04)

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