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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850423
Report Date: 09/24/2026
Date Signed: 09/24/2026 04:23:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2026 and conducted by Evaluator Quoc Huynh
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20260526120211
FACILITY NAME:IVY PARK AT WOODLAND HILLSFACILITY NUMBER:
195850423
ADMINISTRATOR:LILIT MNATSAKANYANFACILITY TYPE:
740
ADDRESS:20461 VENTURA BLVD.TELEPHONE:
(818) 346-9046
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:127CENSUS: 94DATE:
09/24/2026
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Aurora Israelson - Business DirectorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff are not properly addressing bed bugs in the facility
Facility staff did not safeguard resident's personal property
Facility staff did not ensure that resident was adequately fed
Facility staff did not ensure that resident was accorded dignity
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Quoc Huynh and Angela Barutyan conducted a subsequent complaint visit to deliver findings for the above allegations. The LPAs arrived at 12:50PM and met with Business Director (BD) Aurora Israelson and Health Services Director (HSD) Reina Rubi. Entrance interview conducted.

On 05/27/2026, LPA Huynh conducted an initial visit. Between 2:43PM and 5:42PM, the LPA conducted a physical plant tour, interviewed two (2) staff and the Executive Director (ED) Lilit Mnatsakanyan, and reviewed and obtained pertinent documents.

On 08/19/2029, LPAs Huynh and Barutyan conducted a subsequent visit. Between 10:08AM and 11:25AM, the LPAs conducted a physical plant tour and interviewed one (1) resident.

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
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 8
Control Number 29-AS-20260526120211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT WOODLAND HILLS
FACILITY NUMBER: 195850423
VISIT DATE: 09/24/2026
NARRATIVE
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During today’s visit, the LPAs and HSD conducted a physical plant tour at 1:01PM and no immediate concerns were observed. The following was then determined:

Allegations: “Facility staff are not properly addressing bed bugs in the facility,” “Facility staff did not safeguard resident's personal property,” “Facility staff did not ensure that resident was adequately fed,” and “Facility staff did not ensure that resident was accorded dignity”

It was reported that the facility did not properly address bed bugs in Resident #1’s (R1) room, did not safeguard or maintain documentation of R1’s personal property, did not provide R1 with lunch, and did not ensure R1 was accorded dignity.

Between 05/20/2026 and 05/21/2026, R1 disclosed to Staff #1 (S1) that they were experiencing bug bites on their skin, prompting S1 to inspect R1’s room. The room inspection revealed a bed bug infestation originating from R1’s sofa recliner and found throughout R1’s clothing and the remainder of the room. The ED and S1 consulted with a treatment company and their Regional Manager, who advised the facility to pursue chemical spray treatments, despite the ED and S1 advocating for heat treatments. The treatment company instructed the facility to remove R1 from the room, empty the room of personal belongings as much as possible, and prepare for a second spray treatment to occur twenty-four (24) hours after the first. The ED noted that R1 often refused housekeeping services and described R1 as a “hoarder.”

Staff entered R1’s room utilizing personal protective equipment (PPE) and began bagging R1’s belongings per the treatment company’s guidance. S1 reported that belongings were bagged by general category and that items identified as excessively infested–including sandals, clothing, a comforter, and recliner–were discarded. S1 confirmed that no inventory list was completed. During the removal process, Staff #2 (S2) conducted a skin assessment and instructed staff that R1 required a shower. It was reported that staff stripped R1 of their clothes and R1 showered independently with staff supervision. Staff then completed the removal of belongings and S1 stated that restroom contents were not collected because R1 was in the restroom without clothes on and all other belongings had already been bagged.

Report Continued on LIC 9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20260526120211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT WOODLAND HILLS
FACILITY NUMBER: 195850423
VISIT DATE: 09/24/2026
NARRATIVE
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S2 later returned to R1’s apartment for a follow up skin assessment and observed R1 unclothed and standing in their hallway between the restroom and front door. R1 reported to S2 that they were not provided lunch. S2 then requested food delivery to R1’s room. It was reported that between approximately 11:30AM and 1:30PM, R1 remained in the infested room without clothing. S2 stated that they notified staff to provide R1 clean clothes and expressed concerns to the ED regarding R1 being left unclothed in an infested room.

The facility attempted to contact R1’s Power of Attorney (POA) throughout the day and was unsuccessful. The POA later returned the facility’s call and inquired about available/vacant rooms for relocation. The ED informed the POA that the facility was “at capacity.” It was reported by staff that the ED did not want R1 placed in any available room due to concern about spreading the infestation. The ED stated that R1 was independent and had agreed to be relocated to a hotel. The ED reported that they personally purchased clothing and essential items prior to R1’s hotel check-in. R1 was checked into a nearby hotel between approximately 6PM and 7PM same day on 05/21/2026.

On 05/22/2026, S2 visited R1 at the hotel. R1 reported being cold and was observed to only have two (2) pairs of pajamas. S2 purchased R1 additional clothing including a jacket and essential items after observing R1 brushing their hair with a fork. Records showed the first chemical spray treatment occurred on this day. On 05/23/2026, S2 returned to the hotel, provided clean clothing, and collected items to be laundered at the facility. Meals and activity sheets were delivered to R1 throughout their hotel stay.

On 05/24/2026, R1’s hotel reservation ended and R1 was at risk of being escorted out. The facility transported R1 to a second hotel and reserved a room for one (1) day. A second chemical spray treatment was completed at approximately 9PM. S1 believed that the previously established twenty-four (24) hour interval was not followed due to the holiday weekend. Staff reported that the technician cleared R1 to return to their room after 3PM the following day (05/25/2026).

Report Continued on LIC 9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20260526120211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT WOODLAND HILLS
FACILITY NUMBER: 195850423
VISIT DATE: 09/24/2026
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On 05/25/2026, R1 checked out of their hotel. R1 and the POA inspected the room and observed dead bed bugs on the clean linens and noted that no bed sheet was provided. The ED and S1 explained this could occur as bugs crawled out and died, indicating the treatment was effective. R1 and the POA were not comfortable returning under these conditions. The ED stated it was their choice, and R1 returned to the hotel.

On 05/26/2026, the POA visited the facility and observed R1’s bed had new linens presumably from the model room. Upon inspection, dead bugs were found on top of and underneath the blanket, similar to the previous day. The POA explained that had R1 returned, the bugs would have crawled onto R1 and died. The POA also reported that R1’s wallet and cash were missing and requested access to R1’s bagged belongings. Staff escorted the POA to the basement parking garage, where several black bags containing R1’s belongings were observed scattered in a corner. On 05/27/2026, S1 reported they had washed and disinfected R1’s belongings and had begun the process the previous day, completing approximately fifteen (15) bags. S1 and the ED stated all belongings were returned to R1’s room.

LPA Huynh inquired why R1 was not temporarily placed in another room at the community. The ED stated the facility and sister facilities were at capacity. The LPA pointed out vacant rooms observed during the tour. The ED stated those rooms were reserved for incoming move-ins and that the only available room was the model room in the memory care unit. The ED stated R1 could not be placed in the model room due to risk of spreading infestation and that the room was not suitable for living despite being fully furnished. The LPA noted a bed could be obtained; the ED responded that this would risk introducing more bed bugs and that no extra beds were available in storage or at sister facilities.

The ED stated that relocating R1 into another unit would risk infestation to other residents. The LPA clarified that R1’s room was infested, not R1. The ED replied that R1 was in fact infested because “bed bugs lay eggs on the skin.”

Report Continued on LIC 9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20260526120211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT WOODLAND HILLS
FACILITY NUMBER: 195850423
VISIT DATE: 09/24/2026
NARRATIVE
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The LPA noted that if this were the case, the facility should not have allowed R1 to return on 05/25/2026 under unacceptable conditions and then state it was R1’s choice to return to the hotel. On 06/03/2026, a temporary room became available and R1 returned to the facility. The date R1 returned to their original room is unknown.

Interview with R1 revealed the entire bed bug situation was distressing. R1 confirmed that staff stripped them of their clothing when the infestation was discovered. R1 stated that they felt awkward, uncomfortable, and vulnerable. After showering independently, no clothing was provided because all belongings had been removed. R1 remained unclothed for an extended period and missed a meal. Staff later requested a meal be delivered to R1’s room and provided pajamas purchased from a nearby store. R1 also reported that restroom items were not removed and that upon returning to the facility, they again observed bed bugs on the bed and in the restroom. R1 and the POA declined to return under those conditions and remained at the hotel until later placed in a temporary room.

On 08/19/2026, LPA Huynh inspected R1’s room. Despite S1 and the ED stating all belongings had been returned, the closet, dresser, and nightstand were mostly empty. The closet contained three (3) shirts, three (3) pants, a safe box, two (2) pairs of house slippers, one (1) set of bed linens, and several empty hangers. The six (6) drawer dresser contained three (3) pairs of undergarments and socks. R1 reported most of their jewelry was missing and described additional missing items, including shoes, clothing, towels, paperwork, their sofa recliner, and kitchen items. R1 also stated the key to their safe box was stored in a shoe that was not returned, preventing access to the safe box. R1 stated they have been re-wearing the same limited clothing.

Photos and videos confirmed that numerous bags of belongings were collected which was inconsistent with the small number of items returned, the ED’s characterization of R1 as a hoarder, and the facility’s assertion that belongings were returned. Record review showed additional chemical treatments and inspections on 05/30/2026 (which recommended the room be taken out of service), 06/01/2026, 06/15/2026, 07/11/2026, and 07/26/2026.

Report Continued on LIC 9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20260526120211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT WOODLAND HILLS
FACILITY NUMBER: 195850423
VISIT DATE: 09/24/2026
NARRATIVE
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A recorded call with the treatment technician on 05/29/2026 revealed that the technician instructed the facility to fully clear R1’s room—including restroom contents—and recommended steam cleaning the carpet and removing the mattress and recliner. Because the mattress and restroom contents were not removed, the technician stated the treatment was not completed as required. For safety reasons, the technician reported they did not advise the facility to allow R1 to return to the room on 05/25/2026.

Based on interviews, observations, and record review, the facility failed to properly address the bed bug infestation by not following treatment instructions, resulting in incomplete remediation and leaving R1 in an infested room. Staff removed R1’s belongings without creating an inventory and stored the items haphazardly, resulting in numerous missing possessions and failure to safeguard personal property. R1 missed a meal during the incident and was left unclothed for an extended period, placing them in a vulnerable and undignified situation. The preponderance of evidence standard has been met; therefore, the allegations are deemed SUBSTANTIATED at this time.

Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 9099-D).

Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20260526120211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT WOODLAND HILLS
FACILITY NUMBER: 195850423
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2026
Section Cited
CCR
87468.2(a)(25)
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(a) In addition to the rights listed in Section 87468.1… (25) To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154.

This requirement was not met as evidenced by:
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The Licensee will provide staff in service training regarding theft and loss. The Licensee will also determine the value of R1's items with R1 and their POA to provide compensation or replacement for lost items. The Licensee will provide CCLD with proof by POC due date.
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Based on interviews and observations, the licensee did not comply with the above section in R1’s personal property were not adequately safeguarded or inventoried which posed an immediate personal rights risk to persons in care.
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Type A
09/25/2026
Section Cited
CCR
87468.1(a)(1)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement was not met as evidenced by:
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The Licensee will provide staff in service training and provide CCLD proof by POC due date.
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Based on interviews, the licensee did not comply with the above section in R1 was stripped of their clothes by staff and left in their room unclothed for a long period of time which posed an immediate personal rights 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.
SUPERVISOR'S NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20260526120211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT WOODLAND HILLS
FACILITY NUMBER: 195850423
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2026
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met as evidenced by:
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The Licensee will provide in service training regarding bed bug protocols and provide CCLD with prood by POC due date.
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Based on interviews and record review, the licensee did not comply with the above section in R1 had bed bugs that the facility did not appropriately address per professional advisement which posed a potential health, safety, and personal rights risk to persons in care.
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Type B
10/01/2026
Section Cited
CCR
87464(f)
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(f) Basic services shall at minimum include:

This requirement was not met as evidenced by:
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The Licensee will provide staff in service training and provide CCLD proof by POC due date.
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Based on interviews, the licensee did not comply with the above section in R1 was not provided lunch which posed a potential health and personal rights 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.
SUPERVISOR'S NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8