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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850067
Report Date: 05/12/2025
Date Signed: 05/12/2025 03:39:43 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
09/12/2024 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20240912104318
FACILITY NAME:VISTA AT SIMI VALLEYFACILITY NUMBER:
565850067
ADMINISTRATOR:LEWIS, MADISONFACILITY TYPE:
740
ADDRESS:1236 ERRINGER ROADTELEPHONE:
(805) 351-8802
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:130CENSUS: 92DATE:
05/12/2025
UNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Madison LewisTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not prevent a resident from developing pressure injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit with the purpose of delivering findings for the above listed allegation. Upon arrival, LPA was greeted by front desk staff. LPA met with Executive Director (ED) Madison Lewis at 02:40PM. Entrance interview conducted.

During an initial complaint visit conducted on 09/13/2024 from 09:30AM to 02:00PM, LPA Brian Balisi conducted physical plant tour, interviewed staff and reviewed and obtained pertinent documentation relevant to the investigation. During a subsequent complaint visit on 05/02/2025, LPA Dulek interviewed 4 (four) facility staff between 10:34AM and 12:17PM. LPA also called, interviewed, and obtained additional documents from the Executive Director. Throughout the course of the investigation, LPA Dulek reviewed all documents obtained. The following was then determined:

The complaint alleges that Resident #1 (R1) developed a stage 3 pressure injury due to R1 not receiving
Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
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 2
Control Number 29-AS-20240912104318
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: VISTA AT SIMI VALLEY
FACILITY NUMBER: 565850067
VISIT DATE: 05/12/2025
NARRATIVE
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proper care at the facility. Record review revealed that R1 moved into the facility on 07/07/2023. At that time, R1’s service plan was at a level 0 care. Service plan indicated R1 was able to care for their own Activities of Daily Living (ADLs) and R1 was able to store and administer their own medications. Physician’s report dated 01/12/2024 indicated that R1 was admitted to hospice care, R1 “needs hands on assistance due to terminal decline” for ADLs including, but not limited to: bathing, dressing/grooming, toileting. At that time, R1 continued to store and administer their own medications. R1’s physician’s report indicates no history of skin condition or breakdown. ED stated that cost was a concern to R1’s family member and that R1 refused to allow an increase in care. ED communicated with both R1 and their family member, who began looking to move R1 to another facility. R1’s family member stated an outside provider would assist R1. Interview with facility staff revealed that R1 was very independent and R1 was able to care for their own ADL needs, even while receiving hospice care. Hospice assisted R1 with showers twice a week. Facility staff indicated that if a resident is bedridden or has a pressure sore, staff will assist with repositioning the resident every 2 (two) hours. However, staff stated that R1 was able to turn and reposition on their own and R1 was not bedridden until the last 2 (two) – 3 (three) weeks R1 resided at the facility. Staff interviewed did not recall R1 having any pressure injuries that they were made aware of. Hospice notes indicate R1 was regularly observed by their chosen hospice care provider, with regular visits in August and early September 2024. Notes reviewed leading up to R1’s hospitalization indicate “pts skin intact” on 09/03/2024. While hospice did document 2 (two) visits on 09/05/2024, documentation indicates R1 “declined further skin assessment, [R1] wanted to sleep.” Record review revealed that R1 did have a pressure injury on their left lower buttock noted “present upon admit” to the hospital. While records reviewed indicate R1 was admitted to the hospital on 09/05/2024 at 09:01PM, pressure injury was not assessed until 09/06/2024 at 12:45PM. Hospital records note “it appears this wound was bigger in the past,” however R1’s skin was noted to be intact during hospice assessment on 09/03/2024. It should also be noted that following R1’s hospitalization, R1’s family changed R1’s hospice provider. Plan of care and visit notes for the new provider do not indicate the presence of a pressure injury/wound. Facility staff interviewed were unaware of R1 ever having a pressure injury, and facility staff were not providing shower assistance or regular direct care to R1, so facility staff would not have been regularly observing R1’s skin for changes. 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. Exit interview conducted and copy of report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC9099 (FAS) - (06/04)
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