565802454-3-16-2022-29-AS-DPEA-CCXPT2-20220328113515

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802454
Report Date: 03/16/2022
Date Signed: 03/16/2022 06:57:10 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
12/08/2020 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20201208123643

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: 85	DATE:	03/16/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Leatrice Bogoyevac		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility doesn’t have an emergency disaster plan that addresses electrical outages

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver final finding for the above allegations. LPA met with administrator and reason for visit was explained.

On 12/08/2020, the Department received information that the facility does not have electricity and the call button is not working, cell phone battery is low and cannot be charged, and the other residents who are on oxygen or assisted living devices are not operating because there is no electricity.

Following is a summary of the investigation:

On 12/17/2020, Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the initial visit complaint investigation was conducted telephonically and allegation was discussed with facility representative Bill Boles. Mr. Boles explained the facility experienced a power outage from 12/7/2020 at around 11AM and it was on and off issue which lasted a day. (continue)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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-20201208123643

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: 03/16/2022

NARRATIVE

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Power was fully restored by 12/8/2020. Mr. Boles stated that during the power outage they purchased lantern lights for each resident and conducted 15min room checks until power was restored. Mr. Boles also stated that there was only one resident with an electrical oxygen tank which they had a back-up battery powered tank for use. Mr. Boles provided a copy of the facility emergency disaster plan specific to electrical/power outage. Mr. Boles stated that the facility is looking into buy a generator for the facility. According to staff a generator was purchased at the time facility had the power outage problem.

Eight (8) of eight (8) residents and other witnesses interviewed during todays visit reported feeling safe at the facility during these changeling time since the pandemic to present.

Based on interviews conducted, there is insufficient evidence to support the allegations.
Therefore the allegations "Facility doesn’t have an emergency disaster plan that addresses electrical outages" is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. A copy of the report and appeal rights were provided by email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC9099 (FAS) - (06/04)

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