565850067-2-29-2024-29-AS-DPEA-D2WUZ6-20240229150100

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850067
Report Date: 02/21/2024
Date Signed: 02/29/2024 02:55:36 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
12/08/2023 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20231208113406

FACILITY NAME:	VISTA AT SIMI VALLEY		FACILITY NUMBER:	565850067
ADMINISTRATOR:	VIVAR, BRIMEN		FACILITY TYPE:	740
ADDRESS:	1236 ERRINGER ROAD		TELEPHONE:	(805) 351-8802
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	130	CENSUS: 94	DATE:	02/21/2024
		UNANNOUNCED	TIME BEGAN:	05:13 PM
MET WITH:	Brimen Vivar		TIME COMPLETED:	05:14 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility's bed bug issue was not handled promptly.
Inadequate staffing to meet the needs of residents.
Staff yell, scream and mock residents.
Medications are not being distributed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver investigation finding. Upon arrival LPA met with Administrator and explained the reason for the visit.

On 12/08/2023, Community Care Licensing Division received the above complaint allegations. Investigation into the allegations consist of records review, tour of resident rooms, interview with residents and staff on 12/13/2023, from approximately 10am-3:30pm.

Following is a summary of the allegations and investigation finding:
Allegations) Facility's bed bug issue was not handled promptly: Information was provided that the facility management did not address the facility bed bug issue promptly. It was alleged that there are four residents that had bed bugs and bed bug bites all over about 6 months and management kept denying it and would just have maintenance spray the rooms. (continue LIC9099c)

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: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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 3

Control Number 29-AS-20231208113406

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: 02/21/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 12/13/2023, between 10am-3:30pm, LPA toured the facility with staff and inspected ten (10) resident rooms (101A, 101B, 105A, 210, 224, 226, 227, 228, 231, and 250) and interviewed six (6) residents. Room observation and interview with residents revealed no current bed bug activity. Residents interviewed did confirm bed bug activity in the past but reported that when it was reported to staff and management the issues was addressed promptly. Interview staff confirmed that the bed bug issues was reported on 5/31/2023 and since then facility Maintenance Director and ECO Lab have worked to rectify the bed bug issues. Records reviewed identified work orders/invoices from ECO Lab from 6/01/2023 to 12/1/2023. The identified rooms were inspected, and treatment was provided for the rooms which were positive with bed bug activity. Also, according to staff and residents’ new mattresses were provided. Six (6) out of six (6) residents interviewed during to tour confirmed that the bed bug issue was addressed promptly.

Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation that “facility’s bed bug issues was not handled promptly”. Therefore, the allegation is deemed unsubstantiated at this time.

Allegation) Inadequate staffing to meet the needs of residents: It was alleged that management schedule only two caregivers for 64 residents and the resident are not getting the quality care that they need. On 12/13/2023, facility staffing schedule provided by management revealed that there are six (6) caregivers total for am/pm shift (3 assigned to Assited Living and 3 assigned to Memory Care) and two (2) med-techs covering the assisted living side and memory care unit. One (1) caregiver and one med-tech for the NOC shift. Interview with staff revealed that at this time the staffing is sufficient. Administrator reported that they also utilize a staffing agency incase it is need if there are call outs or in case additional staffing is needed. Administrator and staff reported that additional staff have been added to ensure residents quality of care is maintained. Staff interviewed confirmed staffing is much better since COVID times.
Ten (10) out of ten (10) residents interviewed reported being satisfied with the services provided by the caregiving staff.

Based on the above information gathered, although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “inadequate staffing to meet the needs of residents” is deemed unsubstantiated at this time.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20231208113406

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: 02/21/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation) Staff yell, scream and mock residents: It was alleged that staff yell, scream and mock residents. Staff interviewed denied the allegation and reported that they have never mistreated any resident and they have not witnessed any staff to be disrespectful with any resident. Ten (10) out of ten (10) residents interviewed on 12/13/2023, denied ever being mistreated by any staff and reported that they have not witness any staff yell, scream or mock any resident of this facility.
Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff are not cleaning resident room” is deemed unsubstantiated at this time.

Allegation) Medications are not being distributed: It was reported that residents’ medications are not being given. No specific details were provided regarding this allegation. On 12/13/2023, random sample of residents medication administration records (MAR) were checked and reviewed with med-tech and no discrepancies were observed. Ten (10) out of ten (10) random residents interviewed did not report any issues with receiving their medications on time. Residents interviewed confirmed receiving medication daily by staff. Staff interviewed denied allegation and expressed that no residents medication is with held unless it is ordered by their physician.

Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Medications are not being distributed” is deemed unsubstantiated at this time.

Exit interview conducted. Copy of the report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3