565850299-3-16-2023-29-AS-MARO-CPYVZQ-20230316165307

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850299
Report Date: 03/16/2023
Date Signed: 03/16/2023 04:53:49 PM

Document Has Been Signed on 03/16/2023 04:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	IVY PARK AT SIMI VALLEY		FACILITY NUMBER:	565850299
ADMINISTRATOR:	BOGOYEVAC, LEA		FACILITY TYPE:	740
ADDRESS:	5300 E. LOS ANGELES AVE.		TELEPHONE:	(805) 583-3500
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	175	CENSUS: 84	DATE:	03/16/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Lea Bogoyevac		TIME COMPLETED:	05:00 PM

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	Licensing Program Analyst (LPA) Martha Arroyo conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Lea Bogoyevac. This is a change of ownership from The Foothills at Simi Valley #565802454 to Ivy Park at Simi Valley #565850299. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The facility is two-story. At 1:05pm, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for one hundred and sixty-five (165) non-ambulatory residents; and ten (10) bedridden residents. The facility has a total of one hundred and forty seven (147) resident bedrooms. The facility has an approved fire clearance for bedridden, front desk will maintain current roster of bedridden residents’ room location. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs, and closet space. The beds are furnished with box springs, comfortable mattress, and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, blanket, and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath, or toilet. There are no staff rooms – awake night staff only on premises. All rooms were free of odors. All window screens were clean and maintained in good repair. The resident bathrooms have a shower with non-skid surfaces. The toilet and shower have grab bars. The hot water temperature was tested in random resident rooms in the Assisted Living area and was found to be within the range of 105 degrees Fahrenheit and 120 degrees Fahrenheit. The hot water temperature was tested in random resident rooms in the Assisted Living area at 1:18pm and was found to be within the range of 105 degrees Fahrenheit and 120 degrees Fahrenheit. The hot water temperature was also tested in random resident rooms in the Memory Care area at 1:42pm and was found to be within the range of 105 degrees Fahrenheit and 120 degrees Fahrenheit. Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT SIMI VALLEY	FACILITY NUMBER: 565850299
	VISIT DATE: 03/16/2023

NARRATIVE

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Report Continued from LIC 809...

At 2:43pm, the LPA conducted a file review or resident and staff records .Resident and staff records are stored in the Executive Director and Human Resources office. Medications are centrally stored in the medications room. There are two (2) medication rooms; one in the Assisted Living area and the other in the Memory Care area. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in the medication room.

Kitchen knives are stored in the kitchen. Stove burners are rendered inaccessible to the residents. The supply of dishes, utensils, pots, pans, and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry, and house cleaning supplies are stored in a locked cabinet located inside the laundry rooms. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are games and/or activity supplies in the activity rooms as well as throughout the facility. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non private bathrooms. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The fire alarm was tested at 1:38pm and functioned properly during the time of the visit. The fire extinguishers were observed and are fully charged. The emergency exiting plans/sketch are posted throughout the hallways. The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights.
Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT SIMI VALLEY	FACILITY NUMBER: 565850299
	VISIT DATE: 03/16/2023

NARRATIVE

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Report Continued from LIC 809C...
The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs where residents can sit. The entire property is fenced. There are no bodies of water on the premises at the time of the visit.

The physical plant of this facility location is in compliance with Title 22 regulations at this time.

Comp III conducted with Applicant Representative.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.
Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC809 (FAS) - (06/04)

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