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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802454
Report Date: 01/31/2023
Date Signed: 01/31/2023 06:53:28 PM

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
10/07/2020 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20201007140003
FACILITY NAME:FOOTHILLS AT SIMI VALLEY, THEFACILITY NUMBER:
565802454
ADMINISTRATOR:BOGOYEVAC, LEATRICEFACILITY TYPE:
740
ADDRESS:5300 E LOS ANGELES AVENUETELEPHONE:
(805) 583-3500
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:175CENSUS: 97DATE:
01/31/2023
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Lea Bogoyevac, Administrator & Vanathda Dunn, Enliven Care DirectorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff mismanaged resident's doctor's orders and other medical paperwork
Facility staff mismanaged resident's medications
Facility staff gave resident's family member wrong information concerning resident's condition
Facility staff failed to seek resident timely medical attention
Facility staff failed to separate resident from another resident with a contagious condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver final finding for the above allegations. LPA met with administrator and reason for visit was explained.

On 10/07/2020, the Department received the above allegations. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures the initial visit on 10/19/2020 was conducted telephonically/facetime. During this visit from 12pm-2pm, a physical plant tour and interview with staff was conducted.

Investigation regarding allegations above consist of interview with staff, random residents, and potential witnesses on: 10/19/2020 from 12pm-2pm, 11/06/2020 from 12:30pm-3:45pm and 3/16/2022 from 11:15am-5:30pm.
Following is a summary of the allegation finding:
Allegations 1) Facility staff mismanaged resident's doctor's orders and other medical paperwork –
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
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 29-AS-20201007140003
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: FOOTHILLS AT SIMI VALLEY, THE
FACILITY NUMBER: 565802454
VISIT DATE: 01/31/2023
NARRATIVE
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It was reported on 09/26/2020 R1 was sent to the hospital as result of COVID-19 symptoms. R1 was subsequently discharged back the following day on 09/27/2020. It was alleged that facility staff did not have or was missing R1’s discharge paperwork. Staff interviewed reported that they did not immediately receive discharge record upon R1’s return. Staff reported that R1 returned to the facility late in the evening on 09/27/2020 and hospital faxed the discharge record later in the day on 09/28/2020 with the new medication order. R1 medication was filled on 09/28/2020 and received on 09/29/2020. No other information provided specific to this allegation. It is unknown what other medical paperwork was mismanaged.

Allegation 2) Facility staff mismanaged resident's medications – This allegation was discussed with reporting party (RP) and it was stated that RP was not aware if either the hospital or the facility was responsible for R1 missing medication (medication name unknown) for two (2) days. No other information provided. Medication missed would be for 09/26/2020 and 09/27/2020 when R1 was in the hospital. RP did not confirm medication name.

Allegation 3) Facility staff gave resident's family member wrong information concerning resident's condition– Information was provided that facility staff did not inform the R1’s family exact date of when R1’s roommate was sick and did not promptly separate the resident from the roommate until after the roommate started coughing. According to records review both residents received positive results around the same time (09/27/2020). Records reviewed revealed that facility first COVID case reported in 9/2020, at which time the facility was in daily communication with Community Care Licensing (CCL) and Ventura County Public Health (VCPH). Per records reviewed, facility was following all guidelines and safety protocols given by public health during the outbreak.

Allegation 4) Facility staff failed to seek resident timely medical attention – Information was received that staff reported R1 was doing well on 10/02/2020. However, on 10/05/2020 it was reported that R1 was observed not doing well and staff was not allowed to call 911. Staff interviewed reported they have never denied any staff to call 911 in any medical emergency. Staff reported that 911 is usually called when residents experiencing a medical emergency like shortness of breath, consistent low oxygen level, chest pain, falls with serious injuries, unresponsive etc. Records reviewed revealed that R1’s oxygen level was record on 10/05/2020 to be 90 and temperature was 97.5. However, due to R1’s shallow breathing R1 was sent to the hospital at approximately 6:55pm on 10/05/2020. No other information provided/available.
continue to LIC9099C.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20201007140003
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: FOOTHILLS AT SIMI VALLEY, THE
FACILITY NUMBER: 565802454
VISIT DATE: 01/31/2023
NARRATIVE
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Allegation 5) Facility staff failed to separate resident from another resident with a contagious condition – Information was received that staff did not separate R1 and roommate until after R1’s roommate showed symptom and developed a cough (date/unknown). Records reviewed showed that R1 was hospitalized on 09/26/2020 and tested positive for COVID-19. According to staff the roommate of R1 tested around the same timeframe. No other information provided/available.

Random residents were interviewed during the course of investigation. Ten (10) out of ten (10) random residents interviewed reported being satisfied with the care provided by staff and feel safe in the community. Residents interviewed did not report any issue with personal care. LPA attempt to interview residents in the "Enliven" (Memory Care) however those residents were unable to understand/communicate with LPA.

Based on information gathered, interviews conducted, and records reviewed there is insufficient evidence to support the allegations made. Therefore, the allegations above are deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report provided to Administrator.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3