Ivy Park at San Marino.

The investigation revealed the following: Allegation - Resident sustained multiple severe pressure injuries due to staff neglect. It is alleged that Resident #1 (R1) was observed with multiple pressure injuries that were not reported until R1 was hospitalized on 6/24/25. It was reported that resident has a right hip unstageable, right heel unstageable, sacral coccyx deep tissue, and right elbow deep tissue. Per the administrator and staff, R1 was receiving home health wound care treatment for the hip and heel. Staff stated they also informed the home health nurse of the redness observed on the lower back. LPA obtained and reviewed documents for R1. Home health documents showed that on 6/20/25, the nurse conducted a head-to-toe assessment on R1 and did not observe any new wound at that time. The nurse performed wound care on the right hip, right heel, and lower back. Six (6) out six staff who provide care to residents stated that when they observe any redness on a resident, they report it right away and determine the care plan. Staff also stated they will reposition the residents more often if needed for any wound care. Per the facility staff and home health documentation, there were no indications of a right elbow deep tissue injury before R1 went to the hospital on 6/22/25. LPA interviewed a total of six (6) residents and they all stated that the staff are nice and assist them right away when needed. Based on interviews and documents reviewed, there is insufficient evidence to show that R1 sustained multiple pressure injuries due to staff neglect. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with the administrator. A copy of this report, along with the appeal rights, was provided.

Allegation: Staff left resident on the ground for an extended period of time. It is alleged that on October 22, 2025 at approximately 10:00 PM, emergency personnel responded to a fall incident, in which resident (R1) was found sitting on the ground in the middle of the room next to their bed. It is unknown how long the resident was on the floor. The complaint alleges caretaker negligence because staff wait for fire department personnel to arrive on scene to complete a basic assessment. Emergency personnel deemed R1 oriented to name, age, city and when asked about pain and injury the resident denied injury. A total of nine (9) residents were interviewed. Three (3) of the residents interviewed recently fell. The residents stated staff respond and leave the residents on the floor until paramedics arrive in case there is broken bones or head injuries. A total of seven (7) staff were interviewed. Staff interviews revealed that resident (R1) is cognitively impaired and resides in the Memory Care Unit of the facility. According to staff, facility protocol in the Memory Care Unit is to call 911 if there is any accident involving a possible head injury, such as and un-witnessed fall. Staff stated that the PM care provider on duty did their last safety check prior to ending their shift at 10 PM, and found the resident sitting on the floor with cris crossed legs. The med-tech on duty was notified, and called 911. While waiting for emergency personnel med-tech assessed the resident by asking them questions and conducting a visual body check. All staff stated that since the resident has Dementia and is a fall risk the followed facility procedures that indicate whenever a Memory Care Unit resident falls they are to immediately call 911 because the residents are cognitively impaired and may not be able to express a change in condition. Based on file review of the Plan of Operation, facility policy regarding medical emergencies- calling 911, and R1's file documents, which indicate the resident is under fall management, there is insufficient evidence to support the allegation. Allegation: Staff are refusing to lift resident back up off the floor. The complaint alleges facility staff called 911 emergency because they needed help in lifting resident (R1) after they fell. It is suspected the facility is using 911 for non-actual emergencies, and expected emergency personnel to lift and transport the resident to bed, even though R1 did not require medical treatment and was not going to be transported to a hospital for treatment. Resident interviews revealed that staff leave the residents on the floor when they sustain falls, and if they are not transported to a hospital staff lift the residents from the floor. All staff denied the allegation, and stated they did not ask emergency personnel to lift R1. They stated that they follow facility procedures that indicate they are to leave any resident that sustains an unwitnessed fall on the ground until emergency personnel assess the resident. Staff stated it is the care provider's responsibility to place a resident back on their bed or chair after they have fallen if they are not transported to the hospital. Staff stated they do not expect emergency personnel to assist with lifting residents if they are not transported. There is insufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated . An exit interview was conducted and a copy of this report was discussed and provided to Kimberly Sanchez.

Licensing Program Analyst (LPA) Galarza conducted a Case Management- Deficiencies visit due to record review findings while investigating complaint control #: 28-AS-20251024145312. The purpose of the visit was explained to Executive Director Kimberly Sanchez. On 10/22/2025 at approximately 10 PM, Memory Care Unit resident (R1) had an unwitnessed falll and was found on the ground in their room. Staff called 911 emergency, notified physician, and family. As of today, an incident report has not been submitted to Community Care Licensing. Per 87211(a)(1) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Departmen t 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. Pursuant to Title 22 California Code of Regulations, a deficiency was cited. Exit interview held with Kimberly Sanchez. A copy of the report and appeal rights were provided.

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. LPA met with Executive Director Kimberly Sanchez. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. There is a Memory Care Unit for cognitively impaired residents. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs). Operational Requirements: The facility has an approved fire clearance for 74 non-ambulatory residents, of which 4 may be bedridden. A hospice waiver for 15 residents is approved. Facility does not handle resident monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 4/1/2026. Physical Plant/Environment Safety: The facility is two 2-story building consisting of "Evergreen" Memory Care Unit , 52 resident rooms, 2 activity rooms, 2 dining rooms, kitchen, dining room, 2 bathique rooms, two TV rooms, library, Bistro room, hair salon, administration offices, laundry rooms, storage areas, 1st floor courtyard/patio area with water fountain, 2nd floor terrace area, courtyard patio area, electrical rooms, staff break room, and parking garage. The interior and exterior physical plant was inspected. Twenty (20) resident rooms, common areas, and kitchen were inspected. Resident rooms have required furniture, bedding, linens, and lighting. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible to residents. The signal system was tested and is operational. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has charged fire extinguishers. The last fire inspection was conducted on 4/30/25 by Pasadena Fire Department. 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 Staffing: A total of 69 staff members provides care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 8/5/2027. Staff have criminal background clearance. Nine (9) staff files were reviewed. They contained 1st Aid/CPR training, criminal background clearance, health/TB screenings, 1st Aid/CPR training, and training records. Resident Records/Incident Reports: 10 resident files were reviewed. They contained Admission Agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and centrally stored medication records. RCFE & Ombudsman complaint posters are posted. Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Executive Chef has a current Food Handling Certificate. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or facility van. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 9/17/2025. Residents with Special Health Needs: There are currently 9 residents receiving hospice services, 7 residents receive home health services, and no residents have prohibited health conditions. Individual Service Plans, Appraisals, and postural support physician orders are on file. No deficiencies were cited. Exit interview was conducted with Kimberly Sanchez. A copy of report was issued.

Allegation: Staff did not allow resident in care to communicate with their family member. It is alleged resident (R1's) family member has attempted to contact the resident but has not been allowed to speak to R1 because staff are following a directive given to staff by the resident's authorized representative. The complaint alleges the resident recently moved in to the facility's memory care unit, and other family members were not aware of the move. Once another of R1's family member learned of the move, they allegedly called the facility requesting to speak to the resident, but the calls were not transferred. A total of seven (7) residents were interviewed, of which all denied the allegation. They stated that they receive phone calls from family without any issues. Resident (R1) stated they speak to family members on the phone. A total of six (6) staff were interviewed, of which all denied the allegation. Staff stated that R1's family member made a call to the facility on April 28, 2025, with the purpose of reporting that staff were not allowing the family member to speak to the resident. Only one (1) staff had knowledge of the supposed calls. The staff member stated last week there was one occasion in which a family member called the facility, and was told to call back because the memory care resident was taking a nap. Therefore, the family member was not able to speak to the resident at the time of the call. Per staff interviews, all residents have access to outside call ers. There are 2 communal phones in the memory care unit in which they may receive phone calls. In addition, the resident rooms have land line phone capability if families wish to open a public phone line. Administration staff stated that there are are instances where a call comes in for a memory care resident, but the resident(s) may be bathing, napping, eating, or having a behavior and the caller is asked to call back at a later time., but usually staff make an immediate effort to get the resident to the phone. All staff stated they have never prevented anyone from speaking to R1 or visiting the resident. Record review indicates R1 has a Durable Power of Attorney and there is no written document and/or restraining order in place that would prohibit staff from allowing any family member access to R1 telephonically or in-person. There is insufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated . An exit interview was conducted and a copy of this report was discussed and provided to Executive Director Kimberly Sanchez.

Allegation: Questionable Death. T h e complaint alleges that on August 17, 2024 97 year old Memory Care resident (R1) woke up between the hours of 5AM- 6AM and informed staff they were having trouble breathing and needed to go to the hospital. According to information obtained, staff called paramedics, but the resident died outside the facility while being transferred on the gurney. It is alleged R1 was healthy; therefore, R1's cause of death i.e., COVID-19 is questionable. A total of three (3) staff were interviewed, of which all denied the allegation. Staff stated that a staff member heard the resident coughing and immediately contacted R1's physician. The resident was taken to their doctor, and developed COVID-19 a week later; August 15, 2024. Staff reported that the night before the resident passed away, they did not feel well but did not have a fever. According to staff interviews, on 8/17/2024 at approximately 6:10 AM, a staff person checked on the resident and found the resident with a black substance around the mouth, left shoulder, and bed pad. According to staff, R1 was alert and oriented and expressed they wanted to be taken to the hospital. Staff observed labored breathing and called 911 emergency. Staff stated paramedics were provided the POLST form, and shortly after exiting the facility R1 went into cardiac arrest. The resident died inside the ambulance. Based on record review, the findings indicate resident (R1) had pre-existing health conditions. Authorized representative was interviewed and no facility negligence was reported. LPA obtained a copy of the Death Certificate that stated the immediate cause of death was COVID-19. There is insufficient evidence to corroborate the allegation. Allegation: Licensee is not ensuring that resident's records are provided to resident's responsible party as necessary. According to information obtained, authorized representative and family member asked facility staff for health records, and were told that the documents would be provided. It is alleged that after several failed requests, family sent a certified letter to the facility on 11/22/2024, but never received any of the documents requested. Staff stated that facility always provides records to responsible parties. However, in this case, the family member requesting the documents was not R1's authorized representative/responsible party. Based on record review, an Advance Health Care Directive was in place, only naming the authorized representative and not the other family member. Authorized representative stated they never requested documents, and the other family member does not have Power of Attorney for health or finances. Therefore, there is no evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated . An exit interview was conducted and a copy of this report was discussed and provided to Executive Director Kimberly Sanchez.

Licensing Program Analysts (LPAs) Galarza & Mayra Cota conducted an announced visit to the facility for the purpose of a Pre-licensing evaluation. LPA met with Executive Director Kimberly Sanchez. An application was submitted to CCLD on 9/29/2023 for a Change of Ownership for a Residential Care Facility for the Elderly for ages 60 years and older. The fire clearance has been approved for a capacity of 74 residents, which 70 may be non-ambulatory and 4 may be bedridden. A hospice waiver for 15 residents has been approved. The facility has a Dementia unit of 19 residents. There are currently 56 residents residing at the facility and 8 are receiving hospice care. Physical Plant : The facility is two 2-story building consisting of a Memory Care unit "Evergreen", 52 resident rooms, 2 activity rooms, 2 dining rooms, kitchen, dining room, 2 bathique rooms, 2 TV rooms, Library, Bistro room, hair salon, administration offices, laundry rooms, storage areas, 2nd floor terrace area, courtyard patio area, electrical rooms, and parking garage. The passageways and walkaways are free from obstructions. The outdoor areas are free of debris/hazards. There is a water fountain in the 1st floor patio area. Residents may have pets. Observations: There are two (2) evacuation chairs in the stairways to be used during an emergency as a path of egress from the facility to safety. The facility does not have surveillance video cameras in place. The two (2) bathique rooms have inoperable bathiques. The 2nd floor bathique room is presently used as a storage room. Per, Executive Director the bathique rooms will be converted to a different use in the near future. 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 Signal System : The signal system was tested and is operational. Fire Inspection : On 5/1/2024 an annual fire inspection was conducted. The sprinkler system, alarms, fire connections, and kitchen hood system were inspected. The last fire drill was conducted on 8/28/2024. Smoke Detectors : There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways Battery operated carbon monoxide detectors were observed in hallways. Appliances: Refrigerators, Stove burners, Oven, Freezers, Washer and Dryer are all working properly. Bedrooms : T here shall be no more than two clients per bedroom. Bedrooms are equipped with a bed, night-stand, overhead lighting, and closet space. Staff bedrooms : No rooms are designated for live-in staff. Bathrooms : All bathrooms have a working toilet, wash basin, and bathtub/shower. Each floor has public restrooms. Public restrooms have an operable call light system. Linen and Hygiene Supplies : Beds have the required linen/supplies which include pillowcase, mattress pads, fitted sheet, blanket and bed spreads. Adequate supply of linens, hygiene supplies, and Personal Protective Equipment (PPEs) are in place. Emergency Phone numbers, exit plan and menu : Posted and readily available for review in the hallway of first floor. All fire extinguishers are fully charged. Toxins: All are stored and locked in supply rooms, locked cabinets, and outdoor storage areas. Water Temperature : The hot water temperature tested between 105-120 degrees Fahrenheit which meets Title 22 regulations. First Aid Kit and Book : A first aid kit was inspected, which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. Facility does not have a First Aid Manual. 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 Food Service : Dishes and cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in the kitchen and only accessible for staff. Food supply is stored in the kitchen and consists of following: 2 days perishable food and 7 days non-perishable food. The freezer was maintained at 0 degrees F and the refrigerator was at 40 degrees F. Food in refrigerators were properly covered to avoid contamination. Dishes, cups and flat ware are stored in the kitchen area. Staff and Residents files : Staff and Residents files are stored and maintained at the facility. Centrally Stored Medication and Destruction Records were reviewed. Facility does not handle cash resources of residents. A surety bond is not in place. Administrator certificate expires 8/5/2025. Liability Insurance : One million dollars ($1,000,000) per occurrence and three million ($3,000,000) in the total annual dollars aggregate. Fire clearance : Granted on 7/10/2024 for 70 non-ambulatory and 4 bedridden residents. Delayed egress is in place in the 2nd floor Dementia "Evergreen" unit. Component III: Component III was waived. The are no items of correction needed. An exit interview was conducted with Administrator Kimberly Sanchez. Due to printing issues a copy of the report will be emailed and mailed. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.