Ivy Terrace at Fullerton.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Case Management to follow-up on an Unusual Incident Report received in the Regional Office. LPA was greeted and granted entry by Concierge and met with Samuel De Guzman, Regional Operations Specialist (ROS). LPA obtained the following documents for Resident #1 (R1): Face Sheet, Identification and Emergency Information, Medical Assessment dated 2/25/2026, Resident Appraisal, Resident Assessment dated 3/15/2026 and R1's Individualized Service Plan dated 3/15/2026. LPA also obtained R1's Advanced Health Care Directive. Advanced Directive, signed by R1, requested all treatments, other than those needed to be kept comfortable, be discontinued. The Regional Office received a Death Report from the facility on 6/2/2026. R1 passed away on May 26, 2026. LPA interviewed Health and Services Director (HSD) and Resident Care Coordinator (RCC) regarding a Death Report received in the Regional Office on June 2, 2026. Resident #1 (R1) moved into the community on May 1, 2021. Per HSD and RCC, resident was declining and was being seen by the Primary Care Physician for a Urinary Tract Infection for the past month. Power of Attorney (POA) was aware. R1 was not on hospice but staff had notified POA that R1 had a change of condition and were discussing different care options when R1 passed away. Paramedics and Fullerton Police Department stated R1's passing was natural and did not need to be referred to the Coroner's Office. Based on LPA's file review and interviews during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Samuel De Guzman, ROS and a copy of the report and LIC 811 were given at the time of the visit.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Concierge at 12:30p,. LPA met with Regional Operations Specialist Samuel de Guzman and explained the purpose of the visit. Currently the facility has thirty-nine residents with a capacity of seventy-two ambulatory; of which twenty five may be non-ambulatory. The facility is approved for a hospice waiver for twenty. Currently the facility is approved for delayed egress and construction is being done with contractors to provide delayed egress doors. Currently, all exit doors are secured and locked. The facility consists of two buildings. The first building is primarily administrative offices and is two floors.. No residents reside in the building. The second building is a single story building with five wings with single and shared apartments. Bathrooms are shared in a "Jack and Jill" fashion in each apartment but there are no showers. Each wing has two restrooms/showers that are used for the community. LPA observed bathrooms had grab bars and non-skid flooring, One bathroom was being renovated but all other bathrooms were in working order. LPA tested the hot water temperature in four of four resident apartments. The hot water temperature was 105.2 degrees Fahrenheit. During today’s visit, LPA toured the facility and inspected the physical plant . Regional Maintenance Specialist Tony Chiasson provided LPA background history on delayed egress and fire inspection reports by vendor Cal Building Systems on April 30, 2026. Fire and carbon monoxide detectors were tested and passed. Fire extinguishers were charged and inspected on March 25, 2026. The facility’s last fire drill was conducted on May 20 2026. (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 (Continued from LIC 809) LPA inspected the kitchen's food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand . Resident modified diets were posted in the kitchen. Emergency supplies were in a storage room with large water storage tanks. LPA toured resident apartments and all rooms had the required furnishings and linens. LPA observed residents in a communal activity. LPA toured the courtyard and observed a shaded seating area and ample outdoor space for activities. LPA reviewed three of three staff training and fingerprint records and reviewed four of four resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on August 28, 2026. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Samuel de Guzman, ROS and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.

It was alleged that R1 was hospitalized for seizures, began complaining of pain on the third day of their hospital stay, was discovered to have hip fractures, and neither the facility, nor R1 due to their dementia, could explain how R1 sustained the fractures which may have been sustained at the facility. When interviewed, AD stated that there were no reports from staff or R1’s home health bath aides or physical therapists of any fall with R1 or any indication from R1’s behavior that they were in pain. Per AD, due to R1’s osteoporosis, the fractures could have occurred spontaneously due to weakened bones, during transport in the ambulance, or at the hospital itself. Three staff interviewed stated they were surprised by R1’s diagnosis, they were unaware of any incidents which could have caused the fractures at the facility, and they did not notice any change in R1’s behavior indicating they were in pain in the days leading up to R1’s hospitalization. Additionally, one of these staff reported that R1’s bed alarm did not register any falls for R1. When interviewed, R1’s responsible party had no concerns about the care R1 received at the facility and noted that the fractures could have been sustained at the hospital, as R1 was transferred between multiple beds at the hospital and R1’s pain was only noted on the third day of their hospitalization. R1’s hospital medical records indicate R1 had hip fractures, but do not discuss how R1 could have sustained these fractures or how long R1 may have had them before they were diagnosed. In addition, R1’s hospital medical records do not indicate that R1 was in pain upon arrival at the hospital. R1’s home health medical records indicate that prior to R1’s hospitalization, home health staff observed R1 sliding forward in their wheelchair at the facility and educated staff on preventing falls from wheelchairs, but contain no information indicating the fractures were sustained at the facility. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

LPA interviewed AD who denied the allegation. LPA interviewed five staff who did not corroborate the allegation. One staff stated that when R1 began to decline, R1 became unable to swallow their medications, facility staff notified R1’s hospice, R1’s hospice discontinued all of R1’s medications, and R1 passed away within the next few days. LPA reviewed R1’s MAR, observed no medication errors, and noted that R1’s medications were discontinued on December 30, 2025, as reported by staff. LPA reviewed R1’s facility care notes which indicate that on December 28, 2025, R1 was no longer able to swallow their medications and hospice was notified and came to see R1. Based on the information obtained, the changes to the administration of R1’s medications were due to R1’s decline and were overseen and approved by R1’s hospice. Regarding the allegation that staff are not ensuring a resident received their meals: it was alleged that R1 was missing their meals. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. Per an incident report received December 31, 2025, R1 passed away from natural causes while on hospice on December 30, 2025. LPA interviewed AD who denied the allegation, stating that staff always assisted R1 with their meals, but R1 was on hospice and declining, and if R1 were not eating, staff would not force R1 to eat but would report R1 not eating to hospice staff. LPA interviewed five staff and did not obtain information corroborating the allegation. Per the five staff interviewed, R1 previously ate well, but began having decreased appetite and ability to eat as they declined, but staff continued to offer R1 food and nutritional supplements and worked with hospice, who changed R1’s diet, to address R1’s dietary needs as they declined. LPA reviewed R1’s Physician’s Report dated December 24, 2025, which indicates R1 is on hospice and has a special diet of pureed food and nectar thick liquids. LPA reviewed R1’s MAR and noted that nutritional supplements were prescribed, given as prescribed, and discontinued on December 30, 2025. LPA reviewed R1’s facility care notes which indicate that in early December 2025, R1 was eating a large portion of their meals, in late December 2025, R1 was eating smaller portions of their meals, taking nutritional supplements, and refusing meals, and by December 28, 2025, R1 was no longer eating and hospice was notified and came to see R1. LPA reviewed R1’s hospice care notes which indicate R1’s hospice visited them multiple times a week and on December 29, 2025, it was noted that R1 was in the process of passing away. Based on the information obtained, the changes to R1’s eating were due to R1’s decline and were overseen and approved by R1’s hospice. The Department has investigated the above allegations and found them to be Unfounded, meaning the allegations were false, could not have happened, or are without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. 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 Regarding the allegation that staff did not prevent a resident from eloping from the facility: it was alleged that R2 wandered out of the facility and fell on the ground. LPA interviewed AD who denied the allegation, stating that while R2 had falls, R2 did not elope. LPA inspected the facility, conducted a health and safety check on R2, and observed R2 in good health with no injuries. LPA attempted to interview R2, but R2 was unable to communicate. LPA interviewed five staff, none of whom were able to confirm whether or not R2 had ever eloped. Two staff interviewed stated that they heard that R2 had either eloped or tried to elope in the past, but were unable to provide additional details of when this elopement may have occurred. LPA reviewed R2’s Physician’s Report dated January 2, 2026, which indicates R2 has dementia with behavioral disturbance, a history of unsafe wandering, and is unable to leave the facility unassisted. LPA reviewed R2’s facility care notes which do not document any elopements, although they do document multiple falls with only minor injuries. LPA reviewed R2’s hospice care notes which do not document any elopements. The information obtained is conflicting. Regarding the allegation that staff are falsifying incident reports: it was alleged that when R2 wandered out of the facility and fell on the ground, but the facility did not properly report it and instead reported that R2 fell inside of the facility. LPA interviewed AD who denied the allegation, stating that while R2 had falls, R2 did not elope. LPA inspected the facility, conducted a health and safety check on R2, and observed R2 in good health with no injuries. LPA attempted to interview R2, but R2 was unable to communicate. LPA interviewed five staff, none of whom were able to confirm whether or not R2 had ever eloped. Two staff interviewed stated that they heard that R2 had either eloped or tried to elope in the past, but were unable to provide additional details of when this elopement may have occurred. LPA reviewed R2’s Physician’s Report dated January 2, 2026, which indicates R2 has dementia with behavioral disturbance, a history of unsafe wandering, and is unable to leave the facility unassisted. LPA reviewed R2’s facility care notes which do not document any elopements, although they do document multiple falls with only minor injuries. LPA reviewed R2’s hospice care notes which do not document any elopements. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

This unannounced Case Management – Health Checks inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check. LPA met with Administrator (AD) Jesus Soto and explained the purpose of the inspection. During the inspection, LPA and AD toured the facility. LPA conducted health and safety checks on the residents present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations and the medications, sharps, and toxins were properly stored. LPA requested and reviewed copies of the resident roster, staff roster, staff schedule, and resident files. Facility representative was advised that at this time further investigation is required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

Licensing Program Analyst (LPA) Lydia Martinez made an unannounced Case Management visit to follow up on an Incident Report received by Community Care Licensing (CCL) on 09/17/2024. LPA met with Administrator (AD) Jesus Soto and RaeAnn Carbal, Health Services Director (HSD) and explained the reason for the visit. LPA interviewed AD Soto and HSD Carbal regarding the circumstances of the reported incident. Incident was self reported via telephone on 09/16/2024. Incident reported stated Resident 1 (R1) was found with both wrist tied together with a strap with about five inches apart on 09/15/2024 at approximately 10:34 pm by Staff 1 (S1). S1, reported the incident to Resident Care Coordinator Mellody Aliado who then reported incident to the AD Soto immediately. An in-house investigation was started that same night and Staff 2 (S2) confessed to restraining R1 to prevent R1 from eating R1's poop. Staff 2 who confessed to restraining R1 was suspended pending the result of their investigation and was not present during LPA's visit. Staff 2 is associated and cleared in Guardian. LPA, along with HSD Carbal conducted a tour of the physical plant and visited R1 who was in the dining room. R1 appeared well kempt with no apparent signs of distress or injuries observed. Facility is undergoing some renovation. Facility was observed clean, safe and sanitary. Residents were observed relaxing in their room or in dining room, No health and safety concerns noted during the visit. LPA requested and obtained the facility's current census, employee roster (LIC500), staff training, as well as most recent physician report and Service Plan for R1. Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with AD Soto and a copy sent to email on file.