565802454-1-24-2023-29-AS-DPEA-CNM4TZ-20230131182358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802454
Report Date: 07/20/2022
Date Signed: 01/24/2023 09:46:37 AM

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
04/29/2021 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20210429105043

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: 87	DATE:	07/20/2022
		UNANNOUNCED	TIME BEGAN:	11:33 AM
MET WITH:	Lea Bogoyevac, Administrator & Vanathda Dunn - Memory Care Director		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility staff did not provide appropriate mobility assistance to resident in care.

INVESTIGATION FINDINGS:

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**This report has been amended to corrected dates (on page 1 line 5 and line 3 on page2), there is no change in the findings.
Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding regarding above allegation.
Following is a summary of the allegation and investigation finding. On 4/29/2021, information was reported that on 4/28/21 resident #1 (R1) sustained a fall when one staff (name unknown) helped this resident who required two (2) person assist transfer from bed to wheelchair. It was also reported that R1 did not sustain any injury or bruising from this fall. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, initial complaint investigation was conducted on 05/06/2021 at approximately 4pm telephonically with staff Sandra Albarran. A virtual physical plant tour was conducted during initial visit and staff were interviewed at approximately 4:45pm. On 03/16/2022, a subsequent visit was conducted at approximately 3:30pm. Additional interviews conducted with staff, random residents and other potential witnesses between the hours of 4pm-5:30pm on 3/16/2022.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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-20210429105043

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: 07/20/2022

NARRATIVE

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Interview and records reviewed revealed that R1 was hospitalization on 4/21/21 and 4/22/201 due to other health conditions and not due to any falls in the month of 4/2021. Staff reported that R1 was a one (1) person assist prior to 4/21/2021 and 4/22/2021 hospitalization. R1 returned from the hospital on 04/27/2021 and due to change in mobility status home health service was requested and started on 04/28/2021. According to staff R1 was provided 2 person assist upon return from hospital. Based on the above information gathered allegation " Facility staff did not provide appropriate mobility assistance to resident in care" is deemed unsubstantiated at this time.

Exit interview conducted and copy of report provided by email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC9099 (FAS) - (06/04)

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