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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802454
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:20:30 PM


Document Has Been Signed on 04/14/2023 04:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, 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: 56DATE:
04/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:56 PM
MET WITH:Lea Bogoyevac, Administrator & Vanathda Dunn, Memory Care DirectorTIME COMPLETED:
04:25 PM
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During the complaint investigation of complaint # 29-AS-20221129161157, the following deficiencies were observed:

On 11/08/2022 Resident #1 (R1) was admitted to Adventist Health Simi Valley Hospital for abdominal pain. R1 was discharged 11/11/2022 with a diagnosis of Acute Pyelonephritis. R1 was admitted to the same hospital on 11/19/2022 for cirrhosis of the liver, ascites, metabolic encephalopathy and diagnosed with acute metabolic acidosis. R1 was discharged on 11/23/2022 and placed on hospice. During both hospital visits, stage 3 pressure injuries were noted to sacrococcyx, ischium and heel. There were no Special Incident Reports (SIRs) or hospice notification submitted to Community Care Licensing (CCL).

Citations issued, exit interview, appeal rights given.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2023 04:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2023
Section Cited

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Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven
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Licensee/Administrator will read and review Title 22 87211 Reporting Requirements and submit plan to report incidents timely. Submit to CCL by 04/18/2023.
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days of the occurrence…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
This requirement is not met as evidenced by: Based on record review, the licensee failed to submit Special Incident Reports (SIRs) for
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R1’s 11/08/2022 and 11/19/2022 hospital admissions, which posed a potential 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: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023
LIC809 (FAS) - (06/04)
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