565802454-1-3-2022-29-AS-DPEA-CAVTKD-20220121134745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802454
Report Date: 01/03/2022
Date Signed: 01/03/2022 01:13:54 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
09/29/2020 and conducted by Evaluator Martha Guzman-Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20200929142439

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:	175	CENSUS: 79	DATE:	01/03/2022
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Leatrice Bogoyevac		TIME COMPLETED:	01:13 PM

ALLEGATION(S):

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Staff handled resident rough resulting in injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial visit was conducted on 09/30/2020 by LPA Zabel Chochian. During today’s visit, LPA Martha Guzman Chavez met with Executive Director, Leatrice Bogoyevac and reason for visit as explained.

On 09/29/2020, the Department received a complaint alleging that “staff handled resident rough resulting in injury”.

On 09/30/2020, between 3:30 p.m. - 4:15 p.m., LPA Chochian 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 virtually via facetime with Bill Boles, the facility Administrator at the time. LPA Chochian discussed the allegation with Mr. Boles and requested copies of documents pertinent to the investigation. The complaint was referred to Community Care Licensing Investigation's Branch (IB) and assigned to Special Investigator Douglas Real.
Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (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)

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Control Number 29-AS-20200929142439

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...

Following is a summary of the investigation conducted by Investigator Douglas Real:

Investigator Real conducted interviews with facility administrator on 11/12/2020; Resident #1 (R1) on 11/12/2020 and 12/29/2020; reporting party on 11/13/2020; facility staff on 11/25/2020, 12/09/2020 and 12/15/2020; random residents on 12/09/2020; R1’s family on 12/11/2020 and 12/29/2020. In addition to the interviews, R1’s facility records, and Adventist Health Simi Valley Medical Records was obtained and reviewed.

During the course of investigation, it was revealed that R1 was admitted to the hospital on 09/25/2020 due to back pain. No external injuries observed/noted and no report of any fall.
It was reported that facility staff #1 (S1) physically abused resident #1, resulting in a fracture to the spine. The facility staff interviewed reported that they never witnessed any abuse or neglect by S1. S1 further denied the allegation. R1 initially denied neglect or physical abuse by S1 and later changed R1s statement. Random residents interviewed expressed that they are happy at the facility and denied any abuse or neglect. R1’s hospital records reviewed indicated CT scans found a non-traumatic compression fracture (of unknown age) as well as mild to moderate anterior wedging of the L2 vertebral body. R1 was found to have diffuse osteopenia with mild to moderate disc spacing, consistent with degenerative disc disease. No signs of abuse noted, and no external injuries identified. Based on the above information, there is not enough evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (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)

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