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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006222
Report Date: 10/09/2026
Date Signed: 10/09/2026 01:49:35 PM

Document Has Been Signed on 10/09/2026 01:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:IVY AT WELLINGTON, THEFACILITY NUMBER:
306006222
ADMINISTRATOR/
DIRECTOR:		ALVARADO, DAVIDFACILITY TYPE:
740
ADDRESS:24903 MOULTON PARKWAY BLDG BTELEPHONE:
(949) 458-2311
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 160CENSUS: 126DATE:
10/09/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator- David AlvaradoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On October 9, 2026, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim made an unannounced visit to conduct a case management visit. LPA met with Administrator David Alvarado and explained the purpose of the visit.

LPA Kim conducted a physical tour of the facility. LPA requested and obtained copies of the following records to review such as staff roster, resident roster, the facility plan of operation, and five (5) resident records which included: admission agreement, physician’s report, appraisal needs and service plan, consent forms, and other pertinent records.

LPA reviewed the facility plan of operation, which included a Dementia Care plan and included the provisions for utilizing resident tracking devices bracelet called the Roam Alert System. The Facility Admission Agreement does not mention any Roam Alert System bracelet in it or any of addendum pages. LPA spoke with ADMIN Alvarado who stated that the Roam Alert System bracelet is similar to a wander guard bracelet. The purpose of the Roam Alert System bracelet is to alert the facility when a resident is near an exit to prevent elopement. The residents who have the Roam Alert System bracelet are provided a bracelet because they have wandering issues and concerns.

LPA observed the facility has five (5) residents who are wearing the Roam Alert System bracelets, and all five (5) residents have been diagnosed with dementia. All consent forms for Roam Alert Systems Bracelets are signed by the residents themselves or their responsible parties. LPA Kim notified ADMIN Alvarado to have
CONTINUED ON LIC809-C
Lourdes Montoya
Edward Kim
DATE: 10/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: IVY AT WELLINGTON, THE
FACILITY NUMBER: 306006222
VISIT DATE: 10/09/2026
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consent forms for Roam Alert System bracelets to have responsible party for R1 and R2 to sign and understand the Roam Alert System Bracelet and send these updated forms to his email address by October 16, 2026, 12:00 PM. LPA observed the Roam Alert System bracelet and it is only removable by another person. There is a device where the bracelet aligns then removes the bracelet. LPA took photos of the Roam Alert System bracelet and how a staff member would remove a bracelet off a resident’s wrist.

An exit interview was conducted and a copy of the report was provided to Administrator David Alvarado.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026
LIC809 (FAS) - (06/04)
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