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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802454
Report Date: 08/05/2021
Date Signed: 08/05/2021 04:08:03 PM



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
07/30/2021 and conducted by Evaluator Martha Guzman-Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20210730090547
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: 75DATE:
08/05/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Leatrice BogoyevacTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Staff handles residents in a rough manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Martha Guzman-Chavez conducted an unannounced initial 10-day complaint visit to this facility. LPA met with Sahar Mosalla and Mariana Pelayo as Administrator Leatrice Bogoyevac was currently in a conference and unavailable. Entrance interview conducted and the reason for the visit was explained.

During today's visit, LPA Guzman-Chavez conducted a brief tour of the physical plant at 1:54pm. In addition, LPA conducted interviews with three (3) facility staff, seven (7) residents, and three (3) resident family members between 2:12pm-3:35pm. During the interviews, it was revealed that all residents feel safe and comfortable at the facility. Residents feel staff are nice and always helpful and had no negative comments to say. Additionally, a file review was conducted and copies of pertinent documentation were obtained.

Continued on LIC 9099c

Unsubstantiated
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: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
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 2
Control Number 29-AS-20210730090547
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: 08/05/2021
NARRATIVE
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Continued from LIC 9099

Based on the information obtained, there is not sufficient evidence to support the allegation of staff handling residents in a rough manner. Therefore, the allegation in deemed Unsubstantiated.

Exit interview conducted, copy of report will be emailed to Administrator.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2