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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610501
Report Date: 04/29/2026
Date Signed: 04/29/2026 02:31:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2026 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20260420122935
FACILITY NAME:IVY PARK AT WEST HILLSFACILITY NUMBER:
197610501
ADMINISTRATOR:LIDIA CAUCHIFACILITY TYPE:
740
ADDRESS:9012 TOPANGA CANYON ROADTELEPHONE:
(818) 701-9550
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:90CENSUS: 68DATE:
04/29/2026
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Myla Belson, Regional Operations Specialist TIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff’s medication administration error led to a resident’s hospitalization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced initial complaint visit. LPA Smith met with the regional operations specialist and executive director trainees and disclosed the reason for the visit.

Staff’s medication administration error led to a resident’s hospitalization

It was alleged that Resident #1 (R1) experienced symptoms of an overdose requiring hospitalization due to R1 being administered the wrong medication and/or dosage. To investigate the allegation LPA Smith interviewed three (3) staff from 11:00am - at 12:20 pm, requested documents relevant to the investigation during interviews and reviewed facility records at 12:35 pm. Interviews with three (3) of three (3) staff reveal the following: R1 was sent to Kaiser on 04/12/26 due to receiving improper medication, was observed to be drowsy and not at baseline. Review of Kaiser discharge records reveal
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
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 3
Control Number 31-AS-20260420122935
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT WEST HILLS
FACILITY NUMBER: 197610501
VISIT DATE: 04/29/2026
NARRATIVE
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(Cont from 9099)

that R1 was admitted on 4/12/26 for drug overdose. R1 was given Supratherapeutic Lorazepam at 2 mg instead of 0.5 mg PRN and Clozapine 25 mg which was no longer prescribed with multiple dose over 1-2 days leading to progressive sedation. Staff acknowledged responsibility for the medication error, and the staff member involved was subsequently terminated; therefore, no further interviews were conducted. Based on interviews and record review, the allegation is deemed SUBSTANTIATED at this time.

Deficiency cited on 9099D

Exit interview conducted/copy of report given
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20260420122935
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT WEST HILLS
FACILITY NUMBER: 197610501
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2026
Section Cited
CCR
87465(c)(2)
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87465 (c)(2) Incidental Medical and Dental Care [...] Once ordered by the physician the medication is given according to the physician's directions. This requirments has not been met:
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Vendored medication training sugested. Proof of registration and/or training due by POC date
POC date: 04/30/26
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Based on interviews and record review licensee failed to ensure medication procedures were followed which led to R1 being hospitalized for drug overdose, which is an imediate health and safety risk to residents 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: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3