IVY PARK AT LAGUNA CREEK

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: The facility did not ensure that resident records were complete, organized, and readily available to facility staff during emergencies.

Official plan of correction

The facility stated that a plan has been implemented to ensure that resident records are readily available for facility staff to assist emergency personnel in any event of emergency.

Deadline recorded: Jul 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(c)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by: Based on interview and record review, the facility did not ensure the reporting of an alleged event involving a staff member slapping a resident. This posed a potential health and safety risk to residents in care.

Official plan of correction

The facility will read Title 22 regulation 87211 and submit a signed acknowledgment of understanding the regulation to LPA by 07/02/2026 via email.

Deadline recorded: Jul 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

" (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. " This requirement was not met as evidenced by: Based on record review and interview, all terms and conditions of residents' admission agreements and/or modifications were not adhered to, which poses a potential health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to provide LPA Moleski with updated admissions documents for R1 and R2 by POC due date. vincent.moleski@dss.ca.gov

Deadline recorded: Oct 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(c)(1)

Regulation authority

CCR

What the official deficiency says

" (c) All information and records obtained from or regarding residents shall be confidential ... (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents... " This requirement was not met as evidenced by: Based on observation, confidential resident records were not stored or safeguarded in a manner which protected their confidentiality, which poses a potential health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to provide LPA Moleski with inservice training records regarding safeguarding confidential records by POC due date. vincent.moleski@dss.ca.gov

Deadline recorded: Oct 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(16)

Regulation authority

CCR

What the official deficiency says

" (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: ... (16) To receive or reject medical care or other services. " This requirement was not met as evidenced by: Based on interviews, facility staff " required " a resident's attorney-in-fact to acquire and pay for third-party one-on-one caregivers, which poses an immediate personal rights risk.

Official plan of correction

Licensee agrees to review the sections referenced in this report and to write a signed statement acknowledging that residents, and by extension their designated attorneys-in-fact, cannot be required to acquire third-party care or supervision services, by POC due date. vincent.moleski@dss.ca.gov

Deadline recorded: Sep 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312(d)

Regulation authority

HSC

What the official deficiency says

" Every facility required to be licensed under this chapter shall provide at least the following basic services: ... (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. " This requirement was not met as evidenced by: Based on interview and record review, facility staff were unaware of R1's general whereabouts for at least 25 minutes, which poses an immediate health, safety, and/or personal rights risk.

Official plan of correction

Licensee has already conducted staff training regarding elopement protocol. Licensee further agrees to provide LPA Moleski with a copy of training sign-in sheets by POC due dates. vincent.moleski@dss.ca.gov

Deadline recorded: Sep 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87631(a)(1)

Regulation authority

CCR

What the official deficiency says

" (a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (1) When care is performed by or under the supervision of an appropriately skilled professional. " This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, a resident with a pressure wound was admitted to this facility without home health or other skilled medical supervision or instruction, resulting in the worsening of the wound over the course of several days, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction Licensee agrees to conduct a training regarding intake procedures and restricted health conditions. Licensee agrees to provide LPA Moleski with a scheduled date for this training by POC due date. vincent.moleski@dss.ca.gov

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, multiple cleaning solutions and other hazardous materials were accessible to residents in care, including memory care residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction Licensee agrees to schedule a staff training regarding storage requirements by POC due date and to notify LPA Moleski of the proposed date of training by POC due date. vincent.moleski@dss.ca.gov

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, medication was stored outside of its originally received container, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction Licensee agrees to conduct a training regarding medication storage procedures by POC due date and to notify LPA Moleski of the proposed date of training by POC due date. vincent.moleski@dss.ca.gov

Official classification

Type B

Official code

87463(h)(1)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, a resident did not receive an annual routine visit with a medical practitioner, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/04/2025 Plan of Correction Licensee agrees to request a routine annual visit for this resident by POC due date. vincent.moleski@dss.ca.gov

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

" (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 ... Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. " This requirement was not met as evidenced by: Based on interview and record review, an incident which threatened R1's health, safety, and/or welfare was not reported to CCLD, which poses a potential health, safety and/or personal rights risk.

Official plan of correction

Licensee agrees to submit to LPA Moleski a written acknowledgement that reporting requirements have been reviewed and will be adhered to in the future. vincent.moleski@dss.ca.gov

Deadline recorded: Jul 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

" (4) The licensee shall assist residents with self-administered medications as needed. " This requirement was not met as evidenced by: Based on interview and record review, a resident did not receive medications as prescribed, which poses an immediate threat to health, safety, or personal rights.

Official plan of correction

Licensee agrees to conduct staff training regarding medication administration. vincent.moleski@dss.ca.gov

Deadline recorded: Dec 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.657(a)

Regulation authority

HSC

What the official deficiency says

“(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.” This requirement was not met as evidenced by: Based on interview and record review, no notification was provided to R1’s RP after rates were raised due to an increase in level of care, which poses a potential health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to write a statement acknowledgement of the requirements and that they will be adhered to in the future. vincent.moleski@dss.ca.gov

Deadline recorded: Jun 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

" (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: ... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. " This requirement was not met as evidenced by: Based on record review and interivews, LPA Moleski did not receive an incident report regarding a resident injury and hospital visit within seven days of the occurrence, which poses a potential health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to write a signed statement acknowledging the requirement to submit incident reports to CCLD in a timely manner. Licensee agrees to submit this statement to LPA Moleski by POC due date. vincent.moleski@dss.ca.gov

Deadline recorded: May 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87506(d)(H)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...(H) Records of current medications as specified in Section 87506(b)(12)...This was not met as evidenced by: On 9/15/2023 the Department representative LPA visited the facility to investigate complaint allegations. While at the facility LPA requested resident medical documents and files. The Licensee did not ensure staff could provide documents requested by the Department as required by Title 22 Regulations. This poses an immediate Health and Safety risk to residents in care.

Official plan of correction

Licensee states they will ensure the documents from previous years are readily available by providing LPA a photo of where the documents are kepty No Later Than (NLT) 10/11/2023.

Deadline recorded: Oct 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(4)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications...This was not met as evidenced by: Based on facility medical record review and witness statements, Licensee did not ensure R1 recieved medication as prescribed. This poses an immediate Health and Safety risk to persons in care.

Official plan of correction

Licensee states on October 3, 2023 there has been a full med tech retraining regarding ordering medication, transcribing medication as well as proper use of physicain phone calls and reminders. Trainnig provided by disctrict nurse for Pegasis Inc. Training documentation will be provided to LPA NLT 10/11/2023

Deadline recorded: Oct 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

22 CCR Section 87465(a)(4) - Incidental Medical and Dental Care: " (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. " This requirement was not met as evidenced by: Based on interviews and review of incident reports and resident records, medications were not administered as required by R1's and R6's doctor's orders, which poses an immediate health and safety risk.

Official plan of correction

Licensee previously conducted staff training regarding medication administration. Licensee agrees to send LPA Moleski training records. vincent.moleski@dss.ca.gov

Deadline recorded: Aug 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on review of R3's resident records, the licensee did not ensure a resident with dementia had their annual medical assessment, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/20/2023 Plan of Correction Licensee agreed to either produce a new LIC 602 for this resident, or provide proof of having scheduled an appointment for a new LIC 602. Licensee agreed to email LPA Moleski records of either the new LIC 602 or proof of the scheduled appointment. vincent.moleski@dss.ca.gov

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) - Maintenance and Operation: " The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. " This requirement was not met as evidenced by: Based on observation, the licensee did not ensure the facility was clean and sanitary such that cockroaches would not proliferate, and/or did not procure maintenance sufficient to prevent the appearance of cockroaches in room F15.

Official plan of correction

Licensee agrees to have pest control arrive and assess and/or address the cockroaches in room F15 by the POC due date.

Deadline recorded: Jul 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

22 CCR Section 87465(a)(5)(A) – Incidental Medical and Dental Services: “(5) … Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician.” This requirement was not met as evidenced by: Based on review of R1’s MARs showing an increase of dosage on October 27, 2022, and based on interviews with administrator Morgan Whinery in which she stated that she could not find a doctor’s order to account for the increase, dosages of this prescribed medication were increased without proper authorization from R1’s physician.

Official plan of correction

Licensee previously conducted training regarding proper medication procedures. LPA Moleski received a copy of this training on May 11, 2023.

Deadline recorded: May 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care - 87465(4): " The licensee shall assist residents with self-administered medications as needed. " This requirement was not met based on LPA review of R1's medication records. This violation poses a potential risk to health and safety of residents in care.

Official plan of correction

Licensee agrees to conduct staff training for medical technicians on transferring doctor's orders to MARs properly. POC due date is 5/11/23. Licensee agrees to submit via email to LPA Moleski proof of training. vincent.moleski@dss.ca.gov

Deadline recorded: May 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

80075(b)(5)(B)

Regulation authority

CCR

What the official deficiency says

80075(b)(5)(B)Health Related Services (b) Clients shall be assisted as needed with self-administration...(5) If the client's physician has stated in writing that the client is unable to determine...(B) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure residents medication was dispensed as prescribed. This poses a potential health and safety risk to residents in care.

Official plan of correction

The licensee stated the staff that were involved in the med error are no longer with community and community wellness director on site will provide in service training to med techs on expectations regarding centrally stored medication and maintaining medication on site per doctors orders. Licensee will provide LPA with training documentation by COB 10/12/2022.

Deadline recorded: Oct 11, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(16)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure residents call button was answered in timely manner. This poses a potential health and safety risk to residents in care.

Official plan of correction

The licensee stated the facility has hired additional staff, including a float staff member, fixed the call button system, and will continue to make repairs to the call button system. Licensee to send a detailed summary regarding staff plan and call button system by POC due date.

Deadline recorded: Oct 13, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(A-D)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 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. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. The use of an Automated External Defibrillator. Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: A review of submitted SIRs and printed dates. Based on file review and dated faxed documents facility did not submit documents timely. This possess a potential health and safety risk to residents in care.

Official plan of correction

Licensee shall provide an in-service regarding the reporting requirments and completion of the Licensing forms to all staff that is in charge of submission of the documents to CCL by POC due date 7/22/22 Proof to be faxed to CCL.

Deadline recorded: Jul 22, 2022. A deadline is not proof that correction was completed.