306005351-6-5-2026-22-AS-LMOA-DUUSUF-20260608141103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005351
Report Date: 05/20/2026
Date Signed: 06/05/2026 02:40:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2025 and conducted by Evaluator Edward Kim

COMPLAINT CONTROL NUMBER: 22-AS-20250519154715

FACILITY NAME:	IVY PARK AT MISSION VIEJO		FACILITY NUMBER:	306005351
ADMINISTRATOR:	FOUDIL MANADI		FACILITY TYPE:	740
ADDRESS:	27783 CENTER DRIVE		TELEPHONE:	(949) 364-6210
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92692
CAPACITY:	150	CENSUS: 116	DATE:	05/20/2026
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator- Foudil Manadi		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff failed to provide adequate treatment after a resident sustained a burn on the premises.
Facility staff did not provide adequate measures to ensure resident did not sustain a burn while in care.

INVESTIGATION FINDINGS:

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** This report was amended due to typographical error""
On May 20, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Administrator (ADMIN) Foudhil Manadi and explained the purpose of the visit.

The investigation consisted of the following. LPA Kim toured the facility with ADMIN Manadi. LPA requested and obtained copies of the resident roster and staff roster. LPA Kim reviewed and obtained copies of R1-R6s records, which include Admission Agreement, Identification and Emergency Information, home health notes, physician's reports, pre-appraisals, reappraisals, progress notes, and other pertinent documents.

The investigation revealed the following:

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 22-AS-20250519154715

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PARK AT MISSION VIEJO	FACILITY NUMBER: 306005351
	VISIT DATE: 05/20/2026

NARRATIVE

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** This report was amended due to typographical error""
Allegation: Facility staff failed to provide adequate treatment after a resident sustained a burn on the premises.
It is alleged that Resident #1 (R1) was brought into the hospital on May 10, 2025, and upon review R1 was found to have a circumferential partial thickness burn with blistering on their left lower leg. It was alleged that there was no care or treatment provided for the burn and they were left untreated for several days.

Based on record review, R1’s Physician Report dated March 10, 2025, diagnoses R1 with Dementia. Charting Notes dated May 9, 2025, at 9:42PM, stated R1 had a round blister. Follow-up encounter notes dated May 9, 2025, stated R1 was seen for follow-up for their blister. It was stated R1 had a blister on their lower left leg and a home health order will be done for monitoring. Wound care is not necessary at this time as there is no break in the skin. Ongoing monitoring and routine care will be continued.

Charting Notes May 10, 2025, at 12:17PM, stated R1 still had the blister and there was no complaint about the blister on their leg. On May 10, 2025, at 1:42 PM stated R1 was sent to the hospital. At 10:05 PM, resident returned to the facility from the hospital. Home health Agency Care Note dated on May 5, 2025, Palliative Care came for heel care wounds, and there are no notes on lower left wound or burns. Home health Agency Care Note dated May 6, 2025, came in for vitals and follow up mentioning no falls were reported and the scab was intact on the heel. There are no notes or concerns of a burn or a wound on the lower left leg. Home health Agency Notes dated May 13, 2025, examined and wrote the injury as a wound and not a burn wound. It stated that they asked R1 if they knew what happened, but R1 stated they did not know how that wound appeared on the lower left leg. Home Health Agency dated May 16, 2025, May 20, 2025, May 23, 2025, May 27, 2025, June 3, 2025, June 17, 2025, and June 24, 2025, that the wound is healing and finally resolved. There are no indications that the wound was a burn wound.

Based on interviews, three out of three staff and two out of four witnesses denied the allegation. One resident and Two out of four witnesses could not confirm or deny the allegation. R1 stated they could not recall when or how they had the wound on their left leg. R1 did not know if it was from a burn. R1 stated the facility treats them well and if they did receive a wound or burn, the facility would provide the best care for them. All three staff stated R1 had a wound. S1 stated they did not suspect a burn when they noticed it

Continued on LIC9099C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 22-AS-20250519154715

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PARK AT MISSION VIEJO	FACILITY NUMBER: 306005351
	VISIT DATE: 05/20/2026

NARRATIVE

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** This report was amended due to typographical error""
when R1 was leaving the facility to the hospital. S3 stated they noticed the wound after R1 returned. Although the charting notes stated 911 was called and family could not pick up the family, S1 stated R1 went to the hospital with their family. W1 and W2 could not confirm when the family took R1 to the hospital but recall it was around early May the family brought R1 to the hospital. W1 and W2 stated when they saw the redness and blister, they did not believe it was from a burn. They believed it was due to a fall. All staff, W1, and W2 stated if it was a burn, the facility would have provided adequate treatment. All staff, W1, and W2 stated R1’s wound was provided adequate treatment prior to hospitalization.

Based on the information gathered, there is no sufficient evidence gathered to confirm the above allegation.

Allegation: Facility staff did not provide adequate measures to ensure resident did not sustain a burn while in care
It is alleged that the facility did not provide adequate measure to ensure resident did not sustain a burn while in care.

Based on Interviews conducted, three out three staff and two out four witnesses denied the allegation. One resident and two out of four witnesses could not confirm or deny the allegation. R1 does not recall how or when the wound happened on their lower left leg. R1 could not verify if the wound was due to being burned. R1 stated the facility does a good job in preventing situations for themselves and residents from being burned. All staff and all witnesses do not know how R1 received the wound. All three staff and two witness stated that R1’s room and common areas do not have anything that could lead to any residents sustaining a burn while receiving care or staying at the facility. W1 and W2 stated that the facility is safe in all areas and in R1’s room that can be ensured that R1 could not sustain a burn while in care or supervision. All three staff stated, R1’s room and the facility is in safe regards to the facility. Based on observations on May 28, 2025, January 9, 2026, and May 20, 2026, LPA observed the facility ensure residents were in safe accommodations. Staff were taking care of residents for their needs and did not observe a situation where any residents sustained a burn or any injury while in care.

Continued on LIC9099C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20250519154715

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PARK AT MISSION VIEJO	FACILITY NUMBER: 306005351
	VISIT DATE: 05/20/2026

NARRATIVE

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** This report was amended due to typographical error""
Based on record review, there is no information on how R1 received their wound. Charting Notes dated May 9, 2025, at 9:42PM, stated R1 had a round blister. Prior to that Home health Agency Care Note dated on May 5, 2025, Palliative Care came and did not note any lower left wound or burns for R1. Home Health Agency Care Notes dated on May 6, 2026, Home Health noted no falls were reported and the scab was intact on the heel with no notes or concerns of a burn or a wound on the lower left leg. There is nothing on R1’s charting notes that show resident had burnt injuries that were not being tended to.

Based on the information gathered, there is no sufficient evidence gathered to confirm the above allegation.

Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations Facility staff failed to provide adequate treatment after a resident sustained a burn on the premises and Facility staff did not provide adequate measures to ensure resident did not sustain a burn while in care. 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.

Exit interview was conducted and a copy of the report was provided to Administrator Foudhil Manadi.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

LIC9099 (FAS) - (06/04)

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