Ivy Park at Bonita.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. LPA identified himself and discussed the purpose of the visit with Executive Director Randal Newton. According to the facility’s license, the facility has a maximum capacity of ninety six (96) residents, of whom eighty eight (88) can be non-ambulatory. Eight (8) may be bedridden and a hospice waiver approved for twenty five (25) residents. LPA, accompanied by Executive Director toured the interior and exterior of the facility, and inspected five rooms in both the assisted living and the memory care unit. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Hot water temperature was measured in the facility at 111 degrees F. The ambient temperature inside the facility was measured at 76 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Their are no bodies of water on the premises. Per Executive Director, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-C] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA reviewed multiple staff and resident records/files. LPA file review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Executive Director Randal Newton whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

LPA interviewed R1 on December 26, 2024 at the facility. R1 was observed to be using a wheelchair. R1 stated that they were doing well. In regards to the facility, R1 stated "It's okay for me" LPA asked R1 how it could be better, R1 stated if their spouse were there and still alive. R1 stated that the staff are "fine, they're ok" LPA asked R1 if any staff member has ever yelled at them or hit them, R1 stated no. LPA asked R1 if they were familiar with S1. R1 stated yes. LPA asked R1 if S1 has ever yelled at R1, R1 stated no. LPA asked R1 if S1 had ever hit or physically abused them, R1 stated no, never. LPA asked R1 if they had any issues or concerns they would like to share. R1 stated no, I have no concerns or issues to share. LPA interviewed Resident 2 (R2) on December 26, 2024 at the facility. R2 stated that they were "doing well" R2 stated that they "like it here" LPA asked why? R2 stated that everyone is very nice. LPA asked R2 if they know S1. R2 stated yes. LPA asked R2 how they felt about S1. R2 stated that S1 is very nice and S1 regularly helps R2 with their wheelchair and other personal needs. R2 stated that R2 has never witnessed or heard of S1 abusing or being unkind to another resident. LPA interviewed Resident 3 (R3) on October 23, 2025, R3 stated that they recently came back from a skilled nursing facility and they were happy to return. R3 stated that they "love it at the facility." R3 stated that the food is great and the residents and staff are all friendly. R3 stated that they know S1. R3 stated that S1 is very hardworking and is always "bouncing around." R3 stated that S1 will help you with anything. R3 denied any verbal or physical abuse by S1 or any other staff member. LPA interviewed S1 who stated that they have worked at the facility for over one year. S1 stated that they work the "PM shift." S1 stated that some of their job duties include showering residents and preparing them for bedtime. LPA asked S1 if they have ever had any issues with resident's in the past. S1 stated that only with R1. S1 stated that R1 can be very aggressive and difficult at times. S1 stated that R1 will sit in the lobby area and complain all day. S1 stated that they have witnessed R1 be rude with other facility staff as well. S1 denied any physical or verbal abuse towards R1. LPA interviewed Staff 2 (S2) at the facility. S2 stated that they are R1's main caregiver and they know R1 very well. S2 stated that R1's dementia has gotten worse recently and R1 does not remember names, only faces. S2 stated that R1 has a lot of mood swings throughout the day. S2 stated that R1 is "hit or miss," R1 is either really happy to see you or R1 wants you to leave them alone. S2 stated that they have witnessed R1 sitting in the lobby area telling people to "shut up." 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA interviewed Staff 3 (S3) at the facility. S3 stated that they interact with R1 on a regular basis. S3 stated that R1 does not like to hear sounds and will regularly tell others to "shut up." S3 stated that immediately after R1 eats their meals in the dining area R1 demands staff to move R1 to the lobby area without delay. S3 stated that since R1 has to wait a few minutes for staff to move R1 to the lobby area, R1 becomes upset and has yelled at staff in the past. S3 denied ever witnessing or any knowledge of staff members being abusive towards R1. LPA interviewed outside source (OS) regarding the complaint allegation. OS stated that R1 is not in their right mind. OS stated that they recently visited R1 and assist R1 with bill pay. OS stated that R1 is clinically depressed, gets agitated and thinks things happen, that never happened. OS stated that R1 advised them last week that they fell. OS confirmed with the facility that R1 did not fall. OS stated that R1 can be very difficult if R1 does not like someone. OS stated that they are aware that R1 had issues with S1 in the past. OS stated that they do not believe that S1 physically or verbally abused R1. Based on interviews, 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 Randal Newton, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit.  LPA was greeted by and met with Executive Director Randal Newton,to discuss the purpose of the visit. LPA delivered an amended complaint investigation report. No deficiencies were cited or observed on this date. An exit interview was conducted with Randal Newton, who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.

S1 stated that their are various reasons a medication would not be dispensed to a resident, but regardless of the reason it is always logged in the MARs. S1 stated that when they dispense medication to a resident, everything has to be "grayed" out on the computer system, meaning the medication was logged and charted and they can move on to the next resident for "med-pass." LPA interviewed Staff 2 (S2) who stated that they have worked at the facility for over four years. S2 stated that they work both in the memory care unit and assisted living. S2 stated that whenever a resident is not given their medication the reason is logged in the "system." S2 stated that their would never be a time when a staff member would not log in a medication that was not dispensed. S2 stated that S2 meets every week with unit directors to discuss the "exceptions" or the medications that were not dispensed and "trends." S2 stated that the facility recently changed pharmacies which caused a delay on receiving various medications for residents. S2 stated that R1 has not had any medication errors or missed medication. S2 stated that S2 personally investigates and writes incident reports anytime their is a medication error. S2 stated that they review and discuss the medication error with the unit directors and notify the Executive Director. LPA interviewed Staff 3 (S3) who stated that they have worked at the facility for over 10 years. S3 stated that they dispense medication in both the assisted living unit and the memory care unit. S3 stated that whenever a resident is not given their medication the reason is logged into the computer system. S3 stated that their would never be a time when a staff member would not log in a medication that was not given and the reason. S3 stated that they are familiar with R1. S3 stated that they recall giving R1 their PRN of Tylenol frequently for pain. S3 stated that their were no medication errors or missed medications for R1. LPA interviewed Assisted Living Director (ALD) who stated that R1 was on eight routine medications and four PRN medications during their stay at the facility. ALD stated that prior to a resident going out in the community it is facility protocol to sign out their medications with the person who is taking the resident. If a resident leaves via emergency services a medication list is printed and given along with medication instructions. ALD stated that staff order medications through their house pharmacy or the through the residents’ responsible party. If a resident chooses not to use the house pharmacy, the responsible party will order and deliver medications to the community upon request. If a resident uses the house pharmacy and they do not have medications on hand, it could be due to needing a new signed order from the Primary Care Physician (PCP) or a delay in delivery from the pharmacy. Facility staff along with the house pharmacy would continue to contact the PCP until the medication order is signed and sent to pharmacy. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA Interviewed Memory Care Director (MCD) who stated that R1 was out of the facility several times. On one of those dates R1 had a fall while with their Responsible Party (RP). Upon return R1 was evaluated and given medications. MCD stated that in June 2025 the house pharmacy was being changed. MCD stated that they advised RP that medication refills needed to be done outside of the community. RP advised MCD that PCP sent the medications to a pharmacy in Los Angeles in error. MCD and RP were in regular communication and RP advised MCD that they would order and deliver R1’s medications. Facility would advise RP when refills were needed. MCD advised RP that R1 had a new order of Tylenol with a higher dosage which meant they would no longer dispense the remaining Tylenol. MCD personally signed out R1’s medications to RP. MCD stated that they advised RP that they were giving RP more medication “just to be safe.” RP agreed with MCD. MCD stated per facility protocol they gave RP a copy of medication list and release form. LPA reviewed staff schedules dated May 2025 through July 2025. Staff schedule for assisted living revealed an average of three to four caregivers, two LVN’s and one med tech for the “AM” shift. The “PM” shift had an average of three to four caregivers and one med tech. The assisted living average census was 40 residents. The memory care “AM” staff schedule revealed an average of four caregivers, one med tech and one “floating” LVN. The memory care “PM” schedule revealed an average of four caregivers and one LVN. The memory care average census was 20 residents. LPA reviewed Medication Administration Records (MAR's) for R1 for the dates of May 1, 2025 through July 31,2025. A Doctor's order for Acetaminophen was received on June 13,2025. Acetaminophen was a "PRN" which would be dispensed as needed. LPA reviewed R1's charting notes dated May 2025 through July 2025. On multiple dates R1 denied any pain and discomfort. During the month of July R1 had falls and an injury which the PRN was given more frequently. Review of R1's MAR's found that all of the medications were dispensed as prescribed. The dates that the medications were not dispensed were due to; resident refusal, out in the community or medication not available. The MAR's was logged properly with dates and staff initials. No records were found to show that a medication error had occurred. Review of internal charting notes revealed regular communication with R1's Physician regarding medication and care needs. Based on interviews, 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 Randal Newton, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. This is an amended version of the original report created on August 6, 2025.

Licensing Program Analyst (LPA), Ramon Serrano, conducted an unannounced collateral visit as a follow-up for an unrelated complaint investigation for another facility. LPA was greeted by the front desk receptionist and then met with Executive Director Randal Newton, LPA then discussed the purpose of the visit. During the visit, LPA interacted with staff and residents and obtained facility records. An exit interview was conducted with Randal Newton and copy of this report along with Licensee Rights (LIC 9058 3/22) was provided to Randal Newton whose signature below verifies receipt of these rights.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit.  LPA was greeted by and met with Executive Director Randal Newton, to discuss the purpose of the visit. Today's visit is in response to the self reported medication error for Resident 1 (R1) (see LIC811 Confidential List of Names) received on January 30, 2025. It was reported that R1 was given Parkinson's disease medication instead of antibiotic. R1's Physician was notified as well as R1's responsible party. Physician instructed care team to monitor for side effects, but did not believe any side effects would occur. Records review of R1's Physician's Report revealed that R1 has a primary diagnosis of senile degeneration of the brain and is not able to administer their own medications. LPA interviewed staff and collected records. A wellness check was completed; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Randal Newton, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.

Licensing Program Analyst (LPA) Ramon Serrano, conducted an announced Pre-Licensing inspection. LPA met with Executive Director Randal Newton and we discussed the purpose of the visit. LPA conducted a tour of the facility, both inside and outside. Their are no bodies of water on the premises. LPA inspected three resident rooms in both the assisted living section and the memory care unit. The smoke and carbon monoxide alarms were present. Toilets intended for resident use were operating as intended, and bathing facilities were observed to be clean and kempt. The windows, curtains and paint throughout the rooms and the facility, were observed in good condition. Each room intended for resident use had the appropriate furniture, bedding and appropriate lighting. Licensee stated there are no firearms stored on the premises. Hot water temperature was measured at different locations throughout the facility including resident rooms and the two kitchen areas. The average hot water temperature was 115 degrees F. The ambient temperature inside the facility and resident rooms was measured at an average of 74 degrees F. The facility was observed to be clean and kempt with no strong malodors. The main kitchen refrigerator and freezer was observed to be clean and operational, with an ample amount of food to meet resident needs. Cleaning solutions were also properly secured in the various laundry rooms and storage areas. The Component III portion of the application process was completed with Executive Director Randal Newton on today's date as well. Pre-Licensing is complete and this facility has no deficiencies. An exit interview was conducted with Randal Newton and a copy of this report along with Licensee Rights was provided to Randal Newton whose signature below verifies receipt of these.