565802454-1-31-2023-29-AS-DPEA-CP45PQ-20230215190818

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802454
Report Date: 01/31/2023
Date Signed: 01/31/2023 06:03:45 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
10/16/2020 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20201016142513

FACILITY NAME:	FOOTHILLS AT SIMI VALLEY, THE		FACILITY NUMBER:	565802454
ADMINISTRATOR:	BOGOYEVAC, LEATRICE		FACILITY TYPE:	740
ADDRESS:	5300 E LOS ANGELES AVENUE		TELEPHONE:	(805) 583-3500
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	175	CENSUS: 97	DATE:	01/31/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Lea Bogoyevac, Administrator & Vanathda Dunn, Enliven Care Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff did not observe change in resident's health condition
Facility staff did not obtain timely medical care for resident, resulting in hospitalization
Resident was sedated
Facility staff were not meeting residents needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to issue final finding for the above allegations. LPA met with administrator and reason for visit was explained.

On 10/16/2020, the Department received information that facility staff were not meeting resident #1’s (R1) needs, did not observe change in R1’s health condition and did not obtain timely medical care resulting in hospitalization on 07/03/2020. It was reported that R1 was observed by a visitor on 07/03/2020 who requested R1 to be sent to the hospital. It is alleged that R1 was septic because the UTI was not promptly treated. It was also alleged that R1 appeared to be sedated (dates unknown) causing R1 to be lethargic and sleepy. Furthermore, it was alleged that upon discharge from facility on 8/29/2020 R1 was observed to have lost a considerable amount of weight (114lb to 98lb).

Investigation regarding allegations above consist of interview with staff, random residents, and records review on: 10/29/20 from 12pm-2pm, 11/06/20 from 12:30pm-3:45pm and 3/16/22 from 11:15am-5:30pm.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (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)

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Control Number 29-AS-20201016142513

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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Staff interviewed and medical records reviewed revealed that resident #1 (R1) was hospitalized on 7/3/2020 per R1’s responsible person (RP) request. Staff reported that R1 did not show any symptoms, discomfort, or sign of high fever on or prior to 7/3/2020. Staff reported that R1 was observed daily by staff to be stable with normal vitals.

Records reviewed revealed that R1 returned to the facility on 07/09/2020 from hospital with unspecified UTI. New medication was prescribed for the UTI upon hospital discharge. Documentation reviewed confirmed that the following day 07/10/2020, staff did observe change in R1’s condition and contacted 911. R1 was not well and vitals were not normal on 07/10/2020. R1 was hospitalized again and stayed at the hospital from 07/10/2020 – 07/17/2020. R1 return to the facility on 07/18/2020 with new medication for the UTI. R1 was seen by primary care physician on 8/04/2020 and 08/18/2020 post hospital discharge follow-up. R1’s weight was documented at 114lbs at the time of this visit. No other weight record was observed. Records reviewed revealed that R1 was on a Dysphagia diet due to swallowing issues. R1 was not weighed upon move out on 08/29/2020.

Regarding R1's medication - Staff interview and records review showed R1’s medications were recorded, maintained and dispensed according physician orders. No discrepancies noted.

Several attempts were made to reach other potential witnesses and reporting party. No return call received.

Random residents were interviewed during the course of investigation. Nine (9) out of (9) 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 are deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report provided to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (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)

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