565850067-8-29-2024-29-AS-DPEA-D8MTDN-20240830143838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850067
Report Date: 08/28/2024
Date Signed: 08/29/2024 01:03:14 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
02/15/2024 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20240215143207

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: 93	DATE:	08/28/2024
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Madison Lewis, Managing Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Unknown individual in the facility drugged resident in care
Unknown individual in the facility raped resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian initiated a subsequent complaint visit to issue findings for the above allegations. Upon arrival LPA with Madison Lewis, Managing Director and reason for the visit was explained. Also the allegation finding was discussed. .

On 02/15/2024, the Department received a complaint which alleged that an unknown individual in the facility drugged and raped Resident #1 (R1). The time frame of the abuse is unknown but is believed to have occurred in the recent past. It is believed that R1 has dementia. It was also reported that the police are in the process of interviewing R1, staff and other potential witnesses. Community Care Licensing Division’s Investigations Branch (IB) was assigned to obtain police report.

On 02/16/2024, the LPA conducted the initial visit, interviewed staff at approximately 4 p.m. and reviewed documents; completed a physical plant tour and conducted interviews with random residents and R1 from approximately 5 p.m. to 6 p.m.. (Continue to 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: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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-20240215143207

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: 08/28/2024

NARRATIVE

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A review of records, including but not limited to preplacement appraisal, medical assessment, and centrally stored medication record. R1 was admitted to the facility on 11/20/2023. Preplacement appraisal dated 11/13/2023 noted history of short-term memory loss, confusion, agitation, and hallucinations. Medical assessment dated 11/15/2023 noted that R1 has mild cognitive impairment, is able to manage all daily activities with minimal assistance. Staff interviews revealed that R1 has beginning Alzheimer’s disease and noted to have a history of hallucinations. R1’s responsible person also confirmed that R1 does have bouts of hallucinogenic episodes and memory issues. R1 was interviewed by an Officer from the Simi Valley Police Department on 02/12/2024 at approximately 1 pm. R1 did not disclose abuse of any nature. Police report was not generated. Random resident interviews expressed that they are treated well and felt safe in the 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 allegations “Unknown individual in the facility raped resident in care and Unknown individual in the facility drugged resident in care” is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC9099 (FAS) - (06/04)

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