Ivy Terrace at Santa Ana.

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into a self-reported incident report received in the Orange County Regional Office (OCRO) on January 18, 2024, regarding Resident #1 (R1). LPA met with Health Services Director (HSD) Nathan Solares and explained the reason for today’s inspection. Administrator (AD) Judith Torres appeared via telephone. During the course of the investigation, Department staff inspected the facility, interviewed residents and staff, and obtained and reviewed copies of the resident roster, staff roster, an Incident Report received January 18, 2024, Facility Incident Reports regarding R1, R1’s Physician’s Report dated October 3, 2023, R1’s Resident Service Plan dated November 27, 2023, R1’s Resident Service Plan dated February 18, 2024, R1’s Admission Agreement, R1’s X-Ray Report dated January 5, 2024, R1’s Power of Attorney Paperwork, and R1’s Hoag Memorial Hospital Medical Records dated January 13, 2024. Per the Incident Report received January 18, 2024, R1 suffered a fall on January 4, 2024, was diagnosed with a hip fracture on January 10, 2024, and was noted to have discoloration at the fracture site and transferred to Hoag Memorial Hospital on January 13, 2024. Interviews with AD and Staff #1 (S1) revealed that R1 is diagnosed with dementia, is a known fall risk with a history of falls, and engages in wandering around the facility. Per Facility Incident Reports regarding R1, prior to R1’s fall on January 4, 2024, R1 suffered falls on June 10, 2023, and July 26, 2023. AD and S1 reported that there have been multiple instances of R1 being found in other residents’ rooms on the floor or otherwise falling, including incidents not resulting in injuries. 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 When R1 moved into the facility, R1 was ambulatory, but fractured their hip as a result of their fall on July 26, 2023, and became non-ambulatory. To address R1’s fall risk, the facility conducted regular checks (either hourly or every two hours), encouraged R1 to stay in the common area near staff, and installed a small bedrail on R1’s bed, but the bedrail was on the other side of the bed where R1’s spouse sleeps. AD recommended replacing R1’s shoes to R1’s responsible party for better stability, but R1’s responsible party refused. S1 stated that R1 did not have a fall mat and S1 recommended a hospital bed which was refused by R1’s responsible party. Department staff reviewed R1’s Physician’s Report dated October 3, 2023, which indicates R1 has a hip fracture and dementia, uses a wheelchair due to their hip fracture, and is non-ambulatory due to both physical and mental condition. Department staff reviewed R1’s Resident Service Plan dated November 27, 2023, which states that R1 is unable to communicate, engages in wandering behavior without sense of purpose or knowledge of their location, and asses R1’s fall risk as “wheel chair bound ;back from SNF from a fall with fractured hip.” Department staff reviewed R1’s Resident Service Plan dated February 18, 2024, which states that R1 is unable to communicate, engages in wandering behavior without sense of purpose or knowledge of their location, and asses R1’s fall risk as “wheel chair use ;back from SNF from a fall with fractured hip. resident does have moments gets up and tries to walk [themself] without asking for help. resident came back from SNF with weight bearing orders.” Per AD and S1, on January 4, 2024, at around 6:40AM, Staff #2 (S2) found R1 in another resident’s room on the floor, naked, covered in urine, and R1 was unable to communicate to staff what happened. When interviewed, S2 stated that on January 4, 2024, the morning staff had conducted their first check at around 6:00AM. S2 conducted their first check at around 6:10AM and saw R1’s spouse was still in bed and assumed R1 was in bed with their spouse. A short time later, S2 was unable to find R1, searched for R1, and found R1 face down in another resident’s room, naked, and lying in their own urine. After S1 conducted an assessment on R1, S2 gave R1 a shower during which R1 complained about pain. Per S2, a few days later R1 had a bruise on their left shoulder and in the days following the fall, when S2 would take R1 to the bathroom, R1 would complain about pain. Per AD and S1, when R1 was found on the floor on January 4, 2024, S1 conducted an assessment, did not notice any injury, and noted that R1 did not complain about pain, although R1 did complain about pain shortly afterwards while being showered by S2. Facility staff contacted R1’s doctor and responsible party. R1’s doctor requested an x-ray which was taken on January 5, 2024. R1’s Admission Agreement indicates that staff are trained to call 9-1-1 if an injury or other circumstance results in an imminent threat to a resident’s health. 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 facility’s protocol for unwitnessed falls, AD and S1 stated that if the resident shows any sign of pain, the resident should be sent to the hospital. S1 added that in the case of a resident complaining about pain after an unwitnessed fall, the facility will notify their doctor and let their doctor make the medical decision, and that on January 4, 2024, R1’s doctor did not recommend sending R1 to the hospital but did order an x-ray. However, AD stated that R1’s doctor recommended sending R1 to the hospital on January 4, 2024, after being notified of the fall and per R1’s X-Ray Report dated January 5, 2024, the doctor who reviewed R1’s X-Ray also recommended further evaluation after diagnosing R1 with a left femur fracture. When asked why R1 was not sent to the hospital on January 4, 2024, AD and S1 stated that this was because R1’s responsible party did not want R1 sent to the hospital. On January 10, 2024, R1 was noted to have bruises, the x-ray results came back and revealed that R1 had a hip fracture, and R1’s doctor recommended sending R1 to a hospital for treatment. However, R1’s responsible party did not want R1 sent to the hospital unless the injury and pain progressed. Per R1’s Power of Attorney Paperwork, R1’s family member had the power of attorney to make medical decisions for R1. However, per Title 22 regulations, R1’s family member did not have the power to prevent the facility from sending R1 to the hospital to receive necessary medical assessment and treatment under these circumstances. Per AD, on January 10, 2024, R1 was not complaining about pain. However, per S1, on January 10, 2024, R1 was complaining about pain so R1’s doctor prescribed pain pills in addition to recommending that R1 be sent to a hospital. Interviews with AD and S1 revealed that R1 was not sent to the hospital on January 10, 2024, as recommended by R1’s doctor. On January 13, 2024, R1 was noted to have bruises around the injury site which looked yellow and R1 was transferred to Hoag Memorial Hospital. Department staff reviewed R1’s Hoag Memorial Hospital Medical Records dated January 13, 2024, which corroborated that R1 sustained a hip fracture and required surgery. Per AD, the facility’s protocol for fractures is to immediately send the resident to the hospital. However, per S1, R1 was not sent to the hospital on January 10, 2024, because R1’s responsible party did not want R1 sent to the hospital and instead R1’s medical treatment for their hip fracture was delayed for three days until January 13, 2024. The investigation revealed that the facility did not provide adequate care and supervision to meet R1’s needs in light of R1’s known fall risk and wandering behavior which resulted in R1 sustaining a hip fracture, the facility did not seek proper medical attention for R1 on January 4, 2024 as required by the facility’s fall protocol and R1’s doctor’s recommendation, and the facility delayed medical treatment for R1’s hip fracture for three days against R1’s doctor’s recommendation. 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 Based on the information obtained during the course of the investigation, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

On June 27, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Judith Torres Health Services Director Nathan Solares were present and assisted LPA on today's inspection. LPA observed that Judith Torres has a valid administrator certificate which expires on July 15, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for seventy two residents, of which forty six can be non-ambulatory, and has a hospice waiver for fifteen. The facility is a two building complex with the front complex being used for staff offices and the back complex being used for Memory Care. The facility has thirty six resident bedrooms with each resident bedroom being connected to a bathroom, and additionally common bathrooms in the hallways. LPA, accompanied by the AD, conducted a tour of the interior portions of the facility. On today's visit, there are forty two resident in care. LPA observed residents eating lunch in the dining room which included orange chicken, rice, and vegetables. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected seven resident bedrooms and observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA tested the call buttons in resident bedrooms and they tested operational. LPA inspected resident bathrooms and observed them to be clean. LPA observed resident bathrooms to be equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 110 to 115 degrees Fahrenheit. LPA inspected the facility kitchen area and observed it be clean. CONTINUED ON 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 observed the facility to have a minimum two day perishable and seven day non-perishable food supply on hand. LPA observed the facility has a three day emergency food and water supply kept in a storage room. LPA observed multiple fire extinguishers to be mounted in the wall across the facility. All fire extinguishers were observed to be charged and serviced as of April 10, 2025. LPA observed that the facility had their most recent Fire Inspection conducted on April 9, 2025. LPA observed that the facility fire sprinklers and smoke detectors tested during the inspection. LPA observed the facility conducted their last emergency disaster drill on April 7, 2025. LPA observed the centrally stored medication to be kept in locked medicine carts located in the medication room. LPA observed First Aid Kits in the medication room and they had all the required components. LPA observed all the facility's chemicals and toxins to be stored in a locked storage room. LPA observed other common areas such as the dining rooms, staff office, and activity room to be clear of any hazards. LPA, accompanied by the AD, conducted a tour of the exterior portions of the facility. LPA observed the facility has four outdoor courtyard areas for resident use. LPA observed the exterior to be free of obstructions and hazards. LPA observed shaded outdoor seating areas with furniture for resident use. LPA observed the exterior doors to be secured for resident safety. There are no bodies of water on the premises. LPA reviewed the ten resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed residents' medication and medication records. LPA reviewed eight staff files. All staff are background cleared and associated to the facility. Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. LPA spoke with the AD regarding the balance for the facility's annual fees. An exit interview was conducted with Administrator Judith Torres and Health Services Director Nathan Solares. A copy of the report was provided.

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting additional investigation on a self-reported incident report received in the Orange County Regional Office (OCRO) on January 18, 2024, regarding Resident #1 (R1). LPA met with Administrator (AD) Judith Torres and explained the reason for today’s 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 interviewed AD and requested and reviewed copies of 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) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Administrator (AD) Judith Torres. For today’s visit, LPA observed a total of 45 residents in care. LPA observed the Administrator's Certificate for facility AD Judith Torres which expires on July, 15 2024. LPA Ramirez toured the interior and exterior portions of the facility with AD Torres. Facility is a 2-building complex with a single story in each building. The building complex in the front is being used as staff offices. The complex building in the back is the Memory Care and has 36 bedrooms with each bedroom having its own bathroom, and additional common bathrooms. LPA Ramirez observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA observed bathrooms to have hand washing signs posted. Water temperature tested between 107.8-109.4 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged and mounted. LPA Ramirez observed the emergency disaster and evacuation plans, one is located by the front desk lobby and one in the Medication room. CONTINUED ON LIC9099-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 Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care. For the exterior portion, LPA Ramirez observed a shaded patio area with furniture, and observed that the grounds were free of any hazards. During today's visit LPA observed that the residents were participating in the entertainment activity. The entertainment activity consisted of singing and dancing. LPA reviewed five resident files and four staff files. LPA interviewed residents and staff present. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Torres. A copy of this report was provided at the time of exit.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted a case management visit to follow up on an incident report received by Community Care Licensing (CCL) on 04/19/24. LPA was greeted and allowed entrance into the facility by Administrator (AD) Judith Torres. LPA explained the reason for the visit. LPA and AD conducted a toured of the facility. During today's visit LPA interview the AD. Incident report dated 04/19/24 states that on 04/15/24 Resident 1 (R1) was noted with a bruise to their left arm after returning from an outing with family. Records reviewed by LPA Ramirez included the Skin Monitoring: PCA Shower Review dated 04/17/24 for R1. Per Skin monitoring R1 had a bruise to their left arm. During the visit LPA interview AD who reported that the bruise looked like a mark from a hand holding the resident's arm. AD reported that the Primary Care Physican (PCP) was notified and stated that R1 did not need medical attention. An exit interview was conducted with AD Torres and a copy of this report was provided at the time of exit.

During the investigation LPA reviewed documents including the Pacific Coast Medical Services x-ray dated 11/17/23 results for R1. Per Pacific Coast Medical Services R1’s findings stated no displaced fracture of ribs noted and stated rule out fracture. Records reviewed by LPA Ramirez included the Silverado Hospice Staff Communication Note dated 08/02/23-11/20/23. Per Communication Note dated 11/20/23 R1 tolerated shower and wound care well, patient calm and no rib fracture . During the course of the interviews R1’s family member reported that the bruises were not due to staff neglect and stated that staff are very caring. During the interviews, AD stated that R1 did not sustained unexplained injuries while in care and reported that R1 easily bruises. Per AD caregivers are very gentle because R1 bruises easily. During interviews with the Reporting Party (RP), RP reported that she cannot confirm if the injuries were due to staff abuse. Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with AD Torres, and a copy of this report was provided to the facility.

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 Staff #1 (S1) Mayra Martin and explained the purpose of the inspection. Administrator (AD) Judith Torres was not present during the inspection. During the inspection, LPA and S1 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. LPA observed the electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA requested and reviewed copies of the resident roster, staff roster, 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) Jessica Cho continued the Case Management- Other visit in conjunction with a Case Management- Deficiencies visit and to deliver the findings into Complaint Control Number: 22-AS-20201109104853. It was determined upon the file review that the current licensee is the same as the former licensee. An exit interview was conducted with Executive Director Judith Torres, and a copy of this report was provided at the end of the visit.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose to continue the investigation in connection to Complaint Control Number: 22-AS-20201109104853 filed against the former licensee who was operating at this location. LPA met with Executive Director (ED) Judith Torres and explained the reason for the visit. On today's date, LPA interviewed Staff #1 (S1) pertaining to Resident #1 (R1) and obtained copies of previous staff attendance records. ED stated that they will submit dates involving Staff #2 (S2) as discussed during the interview. This will be due on Monday, October 30, 2023 by close of business. An exit interview was conducted with Executive Director Judith Torres, and a copy of this report including the LIC811s were provided at the end of the visit.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose to continue the complaint investigation in connection to Complaint Control Number: 22-AS-20201109104853 filed against the previous licensee who had operated at this location. LPA met with Executive Director (ED) Judith Torres and explained the reason for the visit. On today's date, LPA interviewed staff and obtained additional records pertaining to Resident #1 (R1). An exit interview was conducted with Executive Director Judith Torres, and a copy of this report including the LIC811 were emailed to the Executive Director at the end of the visit.