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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006203
Report Date: 05/18/2026
Date Signed: 05/18/2026 03:52:26 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
02/27/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240227144455
FACILITY NAME:IVY PARK AT SAN JUAN CAPISTRANOFACILITY NUMBER:
306006203
ADMINISTRATOR:PATRICIA RAGERFACILITY TYPE:
740
ADDRESS:32200 DEL OBISPO STREETTELEPHONE:
(949) 496-8802
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:120CENSUS: 76DATE:
05/18/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Kyle Coleman- Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff makes inappropriate comments towards residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of continuing the investigation into the above allegation. LPA met with Executive Director Kyle Coleman and explained the reason for the visit and discussed the allegations. During the course of the investigation, LPA conducted a review of the medications and interviewed seven residents and five staff. Copies of documents pertinent to the allegation was obtained for review: Resident Rosters, Personnel Reports, Staff Contact Information, Face Sheets, Physician's Reports, medication cycle report, and Medication Administration Records.

The investigation revealed the following: Regarding the allegation, Staff makes inappropriate comments towards residents, it is alleged that Staff #1 (S1) would roll their eyes in response to residents' queries and state that their time is being taken away from helping another resident causing residents to feel uncomfortable asking for help. Based on the interviews, six of seven residents and three of five staff denied the allegation concerning S1 and any other staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
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 5
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
02/27/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240227144455

FACILITY NAME:IVY PARK AT SAN JUAN CAPISTRANOFACILITY NUMBER:
306006203
ADMINISTRATOR:PATRICIA RAGERFACILITY TYPE:
740
ADDRESS:32200 DEL OBISPO STREETTELEPHONE:
(949) 496-8802
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:120CENSUS: 76DATE:
05/18/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Kyle Coleman- Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not properly managing the residents' medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of continuing the investigation into the above allegation. LPA met with Executive Director Kyle Coleman and explained the reason for the visit and discussed the allegations. During the course of the investigation, LPA conducted a review of the medications and interviewed seven residents and five staff. Copies of documents pertinent to the allegation was obtained for review: Resident Rosters, Personnel Reports, Staff Contact Information, Face Sheets, Physician's Reports, medication cycle report, and Medication Administration Records.

The investigation revealed the following: Regarding the allegation, Staff are not properly managing the residents' medications, it is alleged Staff #2 (S2) would make repeated medication errors and was not reprimanded by S1. Based on the review of the medications, LPA observed a medication error for Resident #1 (R1). R1 was prescribed two prescription bottles of Spirinolactone- 100mg and 50mg filled on January 18, 2024.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20240227144455
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 SAN JUAN CAPISTRANO
FACILITY NUMBER: 306006203
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by
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ED Coleman stated that medication staff will be retrained on ensuring residents receive their medications as prescribed and properly completing the Medication Administration Record and will submit proof to LPA by POC due date.
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Based on the review of the medications, the licensee did not ensure R1 received assistance with one medication, Spirinolactone, by not administering R1's prescribed medication per the doctor's order which poses a potential health risk to persons in care.
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240227144455
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 SAN JUAN CAPISTRANO
FACILITY NUMBER: 306006203
VISIT DATE: 05/18/2026
NARRATIVE
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Both bottles had a quantity of 60 pills per the prescription labels opened on January 21, 2024. LPA reviewed and counted the remaining tablets twice. There were 13 tablets remaining for the Sprinolactone 100mg and 14 tablets remaining for the Spironolactone 50mg. It was documented on the MAR that R1 received both medications daily in February and March 2024 even though the 100mg bottle had one less tablet. Neither MAR nor the Med Pass Exceptions did not indicate that the medications were refused or not taken from January to March 2024 which corroborates facility failed to properly manage the medications.

Therefore, the preponderance of evidence standard has been met. A deficiency is being cited on the attached LIC9099-D.

An exit interview was conducted with Executive Director Kyle Coleman, and a copy of this report including the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 22-AS-20240227144455
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 SAN JUAN CAPISTRANO
FACILITY NUMBER: 306006203
VISIT DATE: 05/18/2026
NARRATIVE
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One resident indicated having a limited interaction with S1 and did not experience any eye-rolling or negative attitude, however the two staff witnessed S1 rolling their eyes. The one resident and both staff confirmed that S1 did not appear interested or engaged and did not provide assistance to residents. Based on the interviews, there were no clear details to corroborate the allegation.

Therefore, based on interviews which were conducted, 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 following allegation: Staff makes inappropriate comments towards residents is deemed UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Kyle Coleman, and a copy of this report was provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5