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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802454
Report Date: 01/03/2022
Date Signed: 01/03/2022 02:47:40 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2020 and conducted by Evaluator Martha Guzman-Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20200616114658
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: 79DATE:
01/03/2022
UNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Leatrice BogoyevacTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Lack of supervision resulted in Resident #1 (R1) wandering from facility and sustaining injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marth Guzman Chavez conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial visit was conducted on 06/17/2020 by LPA Brian Balisi. During today’s visit, LPA met with Executive Director, ¬¬¬Leatrice Bogoyevac and explained the reason for the visit.

On 06/16/2020, the Department received a complaint in which it was alleged that lack of supervision resulted in Resident #1 (R1) wandering from the facility and sustaining serious injuries that included a laceration on forehead and multiple bruises to face. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Joseph Balarie.

On 06/17/2020, between 12:13 p.m. and 1:09 p.m., LPA Balisi conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically at 12:13 p.m. with Leatrice Bogoyevac, the Executive Director. Between 12:00 p.m. and 1:00 p.m., LPA Balisi conducted telephone interviews with the Executive Director and a video call which consisted of a review of physical plant. LPA Balisi also requested copies of documents relevant to the investigation and noted further investigation would be required. Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
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-20200616114658
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: 01/03/2022
NARRATIVE
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Continued from LIC 9099...

Investigator Balarie conducted interviews with the reporting party on 06/17/2020 at approximately 11:20 a.m.; with R1’s family member on 06/22/2020 at approximately 10:50 a.m.; with Executive Director, Leatrice Bogoyevac on 06/24/2020 at approximately 10:45 a.m.; with R1 on 06/24/2020 at approximately 11:20 a.m. and Resident #2 (R2) at approximately 11:40 a.m.; and with facility staff on 07/02/2020 at approximately 2:05 p.m. and 2:10 p.m. Facility records, Kaiser Permanente Woodland Hills Medical Center medical records, Simi Valley Police Department report, and photos were obtained and reviewed.

On 06/12/2020, at approximately 10:12 p.m., Simi Valley Police Officer responded to the area of Sterns Street and Los Angeles Avenue in Simi Valley, approximately 0.6 miles away from the facility. R1 was found on the ground and bleeding with a large laceration to the top of head. R1 stated R1 tripped and landed on head. Ambulance transported R1 to Los Robles Hospital for treatment. It was later discovered that R1 had exited and wandered away from the memory care facility. R1’s family members were contacted regarding the incident.

At the hospital, R1 was diagnosed with dementia, HTN, hyperlipidemia, CAD and Chronic Kidney Disease Stage 3. R1 sustained a large scalp laceration due to the fall. The laceration was noted to be actively and profusely bleeding from a large left forehead laceration. The laceration was irrigated and closed with staples by plastic surgery. R1 also had several areas of bruises noted on scalp, bilateral eyes, and bilateral cheekbones. While in the Emergency Department, R1 had an episode of tonic-clonic seizure and was admitted to ICU for close monitoring. EEG was negative for seizure activity and R1 was transferred to Kaiser Permanente Woodland Hills Medical Center for further evaluation. On 06/13/2020, R1’s CT scan found no acute intracranial hemorrhage. Resident was discharged back to the facility 06/17/20. Follow-up appointment with plastic surgery was scheduled for 07/10/2020 to remove staples.

Information obtained during Investigator Balarie’s interview with Executive Director, Lea Bogoyevac, found that R1 was last seen by staff on 06/12/2020 between approximately 9:30-9:45 p.m. watching television with the other residents. When staff conducted their scheduled nighttime rounds at approximately 10:00 p.m., R1’s bedroom door was closed. Staff believed R1 was in bedroom and did not want to be disturbed. At approximately 10:20 p.m., Police informed the facility they had found R1 on the street and transported to Los Robles Hospital. Continued on LIC 9099C...
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20200616114658
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: 01/03/2022
NARRATIVE
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Continued from LIC 9099C...

. Executive Director stated she was unsure how R1 exited the facility but believed R1 exited the memory care unit door alone while caregivers entered and exited during a shift change. States R1 did not have a Wander Guard due to R1 was not known to be exit seeking. Executive Director stated cameras monitor the main entrance but are not operational after 9:00 p.m. Investigator Balarie attempted to open a door in the memory care unit without first entering an access code on the keypad. The door easily opened with no keypad combination needed. Executive Director stated the two side doors are usually left open during the day to make it easier for staff to enter and exit the facility. Executive Director stated she would notify staff, moving forward, to keep the doors locked. Investigator Balarie tested the secured double door with a 15 second alarm that sounded before the door would unlock. The door’s alarm sounded for 15 seconds before unlocking and was functional. Information obtained through staff interviews found that on 06/12/2020, there was only one staff on the p.m. shift in charge of the residents for both the first and second floor in the memory care unit. Based on the information and documentation obtained, the inadequate supervision from facility staff allowed R1 to wander out of the facility, undetected, which resulted in an unsupervised fall and hospitalization. Therefore, the allegation Neglect/Lack of Care and Supervision is Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Executive Director was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).

Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20200616114658
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: 01/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/07/2022
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c).

This requirement is not met as evidenced by:
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Licensee will submit a written action plan regarding proper resident care and supervision to CCL by 1/07/2022.
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Based on interviews and records review, the licensee did not comply with the section cited above. (R1) was not provided the proper supervision to ensure resident's safety. R1 left the facility unassisted, which led to a fall and hospitalization, which posed an immediate health and safety risk to residents in care.
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Request Denied
Type A
01/07/2022
Section Cited
CCR
87705(c)
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87705 (c) Care of Persons with Dementia(c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4)There is an adequate number...as identified in his/her current appraisal.
This requirement is not met as evidenced by:
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Licensee will submit staff schedule showing adequate coverage for the memory care unit for all shifts. Submit to CCL by 01/07/2022.
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Based on Information obtained through staff interviews, on 06/12/2020, there was only one staff on the p.m. shift in charge of the residents for both the first and second floor in the memory care unit, which posed an immediate health and safety risks 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 Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20200616114658
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: 01/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/07/2022
Section Cited
CCR
87705(j)
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87705(j) Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
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Licensee will submit memo of understanding to ensure the functionality of the alarmed doors at all times in memory care unit. Submit to CCL by 01/07/2022.
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Based on administrator statement and Investigator Balarie’s testing of the alarmed door, the alarm did not function properly due to doors were unlocked during the day shift for staff ease of entering/exiting, which posed an immediate 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.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5