565800884-6-10-2026-29-AS-DPEA-DVHKC6-20260629074638

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800884
Report Date: 06/10/2026
Date Signed: 06/10/2026 11:11:52 AM

Unsubstantiated

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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2026 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20260320121114

FACILITY NAME:	SIMI OAKS COUNSELING GROUP		FACILITY NUMBER:	565800884
ADMINISTRATOR:	ERNEST W. FEDERER, PHD		FACILITY TYPE:	775
ADDRESS:	2345 ERRINGER ST., STE 106		TELEPHONE:	(805) 581-4357
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	50	CENSUS: 40	DATE:	06/10/2026
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ernest Federer		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not prevent client from pushing someone

Client sustained injuries due to staff neglect

Staff did not prevent a client from punching others

Staff did not ensure client had clothing items on

Staff yelled at client

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver final findings for the allegation listed above. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Ryan Landseadel. Upon arrival at approx. 09:40 a.m. LPA and QAS met with Administrator Ernest Federer and explained the reason for the visit.

On 03/20/2026, The Department received a complaint alleging that “Staff did not prevent client from pushing someone”, “Staff did not prevent a client from punching others”, “Client sustained injuries due to staff neglect”, “Staff did not ensure client had clothing items on” and “Staff yelled at client”. It was further stated that Administrator Ernest Federer was yelling at Client #1 (C1) in frustration, escalating the situation, therefore, was asked to leave by the Police at the scene. Per the Reporting Party (RP), Administrator acted unprofessional and did not utilize proper deescalation techniques.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260320121114

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMI OAKS COUNSELING GROUP	FACILITY NUMBER: 565800884
	VISIT DATE: 06/10/2026

NARRATIVE

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On 03/24/2026, LPA along with the QAS conducted an initial 10-day complaint visit to investigate the above allegation. At approximately 09:30 a.m. LPA conducted a tour of the physical plant, interviewed staff, clients, and reviewed and obtained copies of pertinent documentation relevant to the investigation. On 05/05/2026, LPA reviewed Police body cam footage of the 03/19/2026 incident between approximately 02:03:35 p.m. to 02:05:30 p.m.

It was reported that “Staff did not prevent client from pushing someone”, “Staff did not prevent a client from punching others”, “Client sustained injuries due to staff neglect” and “Staff did not ensure client had clothing items on” as It was alleged that, due to staff neglect, Client #1 (C1) pushed an individual, punched others, sustained an injury and removed articles of clothing. Interviews and record reviews indicated that on 03/19/2026, C1 left the day program after becoming upset when they overheard two individuals arguing. As a result, C1 became agitated and walked away from the facility. Staff #1 (S1) attempted to redirect C1, however, C1 did not respond to S1's efforts and continued walking toward a nearby 7-Eleven. S1 maintained visual supervision and followed C1 at a safe distance. During this time, C1 began swinging their arms in S1's direction. S1 continued monitoring C1 while maintaining an appropriate distance. C1 eventually stopped at a nearby gas station. The 7-Eleven and gas station are located within the same parking lot as the facility. Witnesses in the area observed the situation and began yelling at C1. In response, C1 yelled back, displayed self-injurious behavior and picked up nearby objects such as bottles and a tree branch, which were subsequently thrown in the direction of the bystanders. C1 then removed their shoes, socks, and shirt. S1 informed the bystanders that C1 was under staff supervision and that assistance was being provided.
Additional staff arrived to assist. Law enforcement and C1's family/responsible parties were notified. Staff continued to supervise and monitor C1 until law enforcement arrived on scene. Staff members who responded to provide assistance reported that the Administrator arrived shortly after law enforcement and began speaking with C1. LPA’s interview with eight (8) staff members, including two (2) staff who were present during the incident, and six (6) clients reflected that all individuals did not express concerns regarding staff supervision or staff's response to the incident. Individuals reported no concerns that staff ever failed to prevent individuals from being pushed, punched, or otherwise harmed. Additionally, interviewees did not report concerns regarding staff's supervision of individuals who were not fully clothed during the incident.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260320121114

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMI OAKS COUNSELING GROUP	FACILITY NUMBER: 565800884
	VISIT DATE: 06/10/2026

NARRATIVE

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Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations “Staff did not prevent client from pushing someone”, “Staff did not prevent a client from punching others”, “Client sustained injuries due to staff neglect” and “Staff did not ensure client had clothing items on” have been deemed Unsubstantiated at this time.

It was reported that “Staff yelled at client”. Information gathered during the course of the investigation reflected that on 03/19/2026, there was an incident involving C1. Police body camera footage reflected that C1 was visibly upset over the incident and Simi Valley Police Department (SVPD) officer attempting to calm C1. Footage further reflected that Administrator approaching C1 and stating “What the hell, it’s only been 20 minutes. Did any of this shit have to do with you?” C1 did not respond, looked toward the ground and continued to cry. For the next few minutes Administrator continued to ask C1 questions and make comments which visibly continued to make C1 upset. Due to C1 becoming more upset, SVPD Officer asked Administrator to step away from C1.

Review of the body-worn camera footage did not show the Administrator yelling, shouting, or speaking to C1 in a raised voice. Additionally, LPAs’ interview with eight (8) staff, including (2) staff members who were present during the incident and six (6) clients reflected that all the individuals interviewed reported that they had not observed any staff yelling at clients or speaking to clients in an unprofessional manner. Interview with the Administrator reflected that they were disappointed and frustrated with C1's actions but also stated that they cared about C1. Based on information gathered during the course of the investigation, the Department does not have sufficient evidence to corroborate the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore allegation “staff yelled at resident” is deemed UNSUBSTANTIATED at this time.

Citations will be issued on a separate Case Management report for violations related to the administrator speaking to C1 in an unprofessional manner and failing to properly deescalate the situation.

Exit interview conducted and copy of report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026

LIC9099 (FAS) - (06/04)

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