565802454-5-19-2025-29-AS-KHEN-DH57U2-20250528215737

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802454
Report Date: 05/19/2025
Date Signed: 05/19/2025 05:17:45 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
06/20/2024 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20240620150115

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:	0	CENSUS: 0	DATE:	05/19/2025
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	J Wickliffe Peterson		TIME COMPLETED:	02:17 PM

ALLEGATION(S):

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Staff denied family member access to resident's medical records

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit with the purpose of delivering findings for the above listed allegation. The facility was closed effective 04/10/2023 due to a change of ownership. Therefore, LPA attempted to call the Licensee representative but was unable to make contact.

On 06/20/2024, Community Care Licensing received a complaint against this closed facility. On 06/27/2024, LPA Brian Balisi initiated a complaint investigation for the allegations listed above. At approx. 02:20 p.m. LPA attempted to call the Licensee representative J Wickliffe Peterson but was unable to make contact. Throughout the course of the investigation, LPAs Dulek and Balisi gathered and reviewed copies of relevant documents and LPAs interviewed available relevant parties. The following was then determined:

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025

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 4

Control Number 29-AS-20240620150115

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: 05/19/2025

NARRATIVE

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The complaint alleges that Administrator did not provide Resident #1 (R1)’s family member with requested medical records. Staff interviewed indicated that any resident’s responsible person is able to request records, and the facility will provide the records to the responsible person. Review of R1’s documents revealed that R1’s family member referred to in the complaint is not R1’s responsible person. Staff interviewed indicated if anyone other than the responsible person requests information or documentation from a resident’s file, the staff would refer the requestor to the Administrator for follow up. Interview with Administrator revealed that R1’s family member did request documents. However, when the facility underwent a change of ownership, records were sent out to an alternate location for safekeeping. Some records were returned to the physical address; however, some were not. Administrator did refer R1’s family member to the management company representing the licensee and Administrator offered for R1’s family member or their legal representative to come to the location to copy the requested records, but Administrator stated no one came. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

No citations issued. The facility closed effective 04/10/2023, therefore the report was sent to licensee’s address on record for signature.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
06/20/2024 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20240620150115

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:	0	CENSUS: 0	DATE:	05/19/2025
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	J Wickliffe Peterson		TIME COMPLETED:	02:17 PM

ALLEGATION(S):

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Resident sustained multiple injuries while in care

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025

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 4

Control Number 29-AS-20240620150115

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: 05/19/2025

NARRATIVE

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The complaint alleges that Resident #1 (R1) sustained multiple injuries while in care referring to R1 being dropped in the shower and on 04/09/2018, R1 fell off his wheelchair, resulting in 3 (three) skin tears. LPA reviewed the facility records, including dates this facility was open. The licensee submitted a change of ownership application, which was approved on 07/10/2018. At the time of the alleged incident on 04/09/2018, this facility was not in operation. Additionally, LPA reviewed R1’s available records from this facility, which indicate R1 was admitted to hospice care 02/02/2018. Resident assessment dated 02/01/2018 indicates R1 “requires 1 person total assistance 2x per week. Provided by outside agency.” Outside Provider Communication notes available for review indicated hospice was providing R1’s showers. Based off the information obtained during the course of the investigation, the allegation is deemed UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis.

No citations issued. The facility closed effective date as of 04/10/2023, therefore the report was sent to licensee’s address on record for review and signature.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025

LIC9099 (FAS) - (06/04)

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