306005423-5-12-2026-22-AS-KSGH-DUWUF7-20260610153216

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005423
Report Date: 05/12/2026
Date Signed: 05/12/2026 10:28:31 AM

Substantiated

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
09/26/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230926110556

FACILITY NAME:	IVY PARK AT TUSTIN		FACILITY NUMBER:	306005423
ADMINISTRATOR:	BRENT BROADHURST		FACILITY TYPE:	740
ADDRESS:	12291 S NEWPORT AVE		TELEPHONE:	(714) 544-5959
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	0	CENSUS: 53	DATE:	05/12/2026
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Sandra Acosta-Louer		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident fell and sustained a fatal head injury due to a lack of supervision.
Staff failed to follow residents’ Admission Agreement/Service Plan resulting in resident falling and sustaining a fatal head injury.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver findings on the allegations listed above. LPA Haley was greeted and granted entry by staff after introducing himself and stating the purpose of the visit.

The complaint investigation was initiated by LPA Jerome Haley on September 27, 2023, regarding a complaint filed on September 26, 2023. The complaint was investigated by the Department and consisted of a review of resident records, interviews with staff, a family member of Resident 1 (R1) a tour of the physical plant with Executive Director Brent Broadhurst, and a review of medical records obtained from Providence St. Josph Hospital Orange dated September 26, 2023.

7 of 7 interviews including interviews with the Executive Director (ED), Resident Care Coordinator (RCC), and three Licensed Vocational Nurses (LVN) employed by the facility reveal Resident 1 (R1) was left
Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

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-20230926110556

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 TUSTIN	FACILITY NUMBER: 306005423
	VISIT DATE: 05/12/2026

NARRATIVE

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

alone, unsupervised by staff resulting in the resident having a catastrophic fall and sustaining a fatal intracranial head injury.

Per review of medical records from Providence St. Joseph Hospital dated September 26, 2023, R1 was admitted for a traumatic fall resulting in large left-sided intraventricular/subarachnoid/intraparenchymal hemorrhage with midline shift.

A MD-Hospitalist with Providence St. Joseph Hospital, stated when R1 fell, the resident sustained a large hematoma considered to be a large brain bleed and the brain blood flow could not be stopped. The MD explained, when there’s that much hemorrhaging in the brain, the brain stem has several components including the medulla that regulates breathing causing the patient to stop breathing on their own and as a result, suffer respiratory failure.

Per review of the medical records from Providence St Joseph’s Hospital:
A. Immediate cause of death: acute respiratory failure – interval between onset and death: hours.
B. Underlying cause leading to above: intracranial hemorrhage – interval between onset and death: days.
C. Underlying cause leading to above: traumatic fall – interval between onset and death: days.

A review of R1’s death report dated October 4, 2023, list the immediate cause of death, A: acute respiratory failure. Secondary conditions leading to line A (acute respiratory failure), B. Traumatic Intracranial Hemorrhage, and C. Fall.

R1 had a service plan that included having an escort at all times. When R1 was ambulating with their walker. All staff interviewed, confirmed the staff member assigned to escort R1, stepped away and left R1 alone, unsupervised while the staff member went to open the front door for a guest.

During an interview with the staff member escorting R1 at the time of the fall, the staff member admitted they stood/got R1 up to go to lunch and left R1 alone, unattended to open the front door for a guest. The staff member said they did not feel like they needed to sit R1 down to wait for the staff while they went to the front door to assist someone else. An LVN employed by Ivy Park at Tustin said, R1 was not capable of lifting themselves and should have been sat back down while the staff went to assist the guest at the front door.

Continued on LIC9099C pg 2 of 3

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20230926110556

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 TUSTIN	FACILITY NUMBER: 306005423
	VISIT DATE: 05/12/2026

NARRATIVE

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

Interviews with a family member of R1 and Executive Director Broadhurst, confirmed the facility was being paid to provide escort services for R1 while ambulating to avoid injury, as R1 was considered a fall risk. All caregivers were aware that R1 was not to walk unattended without an escort and R1 always required assistance to ambulate as R1 was unable to ambulate independently. R1’s physicians report dated October 18, 2022, shows R1 was non-ambulatory. R1’s pre-placement appraisal signed October 20, 2022, revealed R1 needed assistance/escorts with transportation and required escorting and/or physical assistance to attend meals and/or activities.

R1 was left standing alone and unattended while the staff escorting R1 went to the front door to perform another task.

An Enhanced Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f).

Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, both allegations: Resident fell and sustained a fatal head injury due to a lack of supervision, and Staff failed to follow residents’ Admission Agreement/Service Plan resulting in a resident falling and sustaining a fatal head injury are found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1.

An exit interview was conducted, and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Citations on this Visit Report are Under Appeal!

Control Number 22-AS-20230926110556

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 TUSTIN	FACILITY NUMBER: 306005423
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type A 05/15/2026 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services – 87464 (f)(1): (f) Basic service shall at a minimum include: (1) Care and supervision as defined in section 87101(c)(3) and Health and Safety Code section 1569.2(c) This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will conduct an in-service training for all staff members and provide a copy of the sign-in sheet for all staff in attendance. Licensee/Administrator agrees to provide an outline of topics covered in the in-service, and the duration of the in-service training.
	8 9 10 11 12 13 14	Per medical record review, when R1 fell, the resident sustained a large hematoma considered to be a large brain bleed and the brain could not stop the bleeding. Excessive bleeding to the brain caused the brain to malfunction which led to R1 suffering from respiratory failure. Per review of R1’s death report, the immediate cause of death was respiratory failure. During interviews, a facility staff member admitted they stood R1 up to go to lunch, and left R1 unattended to open the door for a guest when R1 fell and sustained the fatal head injury. Interviews and record review reveal R1 was non ambulatory, and the facility was being paid to provide escort services for R1 as the resident was considered a fall risk. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Under Appeal Type A 05/15/2026 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will conduct an in-service training for all staff members and provide a copy of the sign-in sheet for all staff in attendance. Licensee/Administrator agrees to provide an outline of topics covered in the in-service, and the duration of the in-service training.
	8 9 10 11 12 13 14	During interviews, a facility staff member admitted they stood R1 up to go to lunch, and left R1 unattended to open the door for a guest when R1 fell and sustained the fatal head injury. Interviews and record review reveal R1 was non ambulatory, and the facility was being paid to provide escort services for R1 as the resident was considered a fall risk. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 4