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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802454
Report Date: 02/16/2023
Date Signed: 02/16/2023 05:22:00 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
02/09/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20230209160819
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: 93DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Vanathda DunnTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility is unsanitary
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced initial 10 day visit for the above allegation. Upon arrival, LPA met with designated staff, Vanathda Dunn and the reason for visit was explained. Entrance interview conducted.

During today's visit, the LPA along with staff conducted a physical plant tour 1:10 pm, toured the kitchen area and observed the dining room at 1:27 pm, conducted interviews with staff, kitchen manager, and nine residents between 1:10 pm and 2:20 pm. At 1:40 pm, the LPA conducted a record review and obtained a copy of the census, staff schedule, reviewed menus, and obtained copies of pertinent documents relevant to the investigation.

Report Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
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 5
Control Number 29-AS-20230209160819
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: 02/16/2023
NARRATIVE
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Report Continued from LIC 9099...

It was alleged the facility is unsanitary. It was reported that tables in the dining areas are frequently dirty and servers do not use gloves and hand utensils to residents after having touched the end of the utensil that would enter the resident’s mouth. During the kitchen and dining area tour, the LPA observed the tables to have a tablecloth and utensils set up for the next meal service. The LPA along with staff observed the tables underneath the tablecloths which appeared to be clean both on top and on the sides. Utensil on the tables were also observed and had no fingerprints or smudges. Staff stated tablecloths are only used for dinner service and not during breakfast or lunch service. Interviews conducted revealed servers do not use gloves; however, they do wash their hands constantly. Additionally, servers clean the tables as the residents finish their meals and go. Furthermore, kitchen staff and servers must undergo training before being able to work in the kitchen and dining room areas. Record review showed kitchen staff and servers have passed and completed the ServeSafe and Food Handler Course. Based on the information obtained, there is insufficient evidence to support the allegation that the facility was unsanitary. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview. Report was reviewed with staff and a copy was given.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/09/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20230209160819

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: 93DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Vanathda DunnTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Residents are not provided proper food service
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced initial 10 day visit for the above allegations. Upon arrival, LPA met with designated staff, Vanathda Dunn and the reason for visit was explained. Entrance interview conducted.

During today's visit, the LPA along with staff conducted a physical plant tour 1:10 pm, toured the kitchen area and observed the dining room at 1:27 pm, conducted interviews with staff, kitchen manager, and nine residents between 1:10 pm and 2:20 pm. At 1:40 pm, the LPA conducted a record review and obtained a copy of the census, staff schedule, reviewed menus, and obtained copies of pertinent documents relevant to the investigation.

Report Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20230209160819
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: 02/16/2023
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that residents are not provided proper food service. It was reported that food at facility is consistently served cold, items on the menu are frequently out of stock, and items ordered from the menu are substituted without checking on resident’s substitute preference first. Review of records revealed on top of the menu the wording “menu is subject to change based on products availability by providers.” Interviews with staff conducted revealed facility menus are made in advance and the facility tries to follow the menu as closely as possible. However, there have been a few times when something becomes unavailable. Unless it is something major where it would alter the entire meal, the chef will make a small substitution to make it adequate. Interviews conducted with random residents revealed that although the food is good at times, there have been many occasions where they receive their food cold. Residents are concerned as they are unsure how the food gets cold because they see the food coming out of the kitchen constantly. Residents stated it has gotten a little better since the food being served cold was more frequent a few weeks ago. However, residents feel the food needs to be served hot every day. Based on interviews conducted with staff and residents, there is sufficient evidence to support the allegation that residents are not provided proper food service. Therefore, this allegation is deemed Substantiated at this time.

Exit interview. Citation issued. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230209160819
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2023
Section Cited
CCR
87555(a)(23)
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General Food Service Requirements. All perishable foods or beverages.. which can cause food infections or intoxication shall be stored in covered containers at appropriate temperatures.

This requirement was not met by evidence by;
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The Administrator will submit a plan on how the facility will ensure the residents food is served hot during meal times and submit to CCL by 2/22/2023
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Based on interviews, the licensee failed to comply with the section cited above, as the residents food has been served cold to residents recently, which poses a potential health and personal rights 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.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5