565850299-4-15-2024-29-AS-BBAI-D4CURR-20240415154911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850299
Report Date: 04/15/2024
Date Signed: 04/15/2024 03:50:04 PM

Document Has Been Signed on 04/15/2024 03:50 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: 131	DATE:	04/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Lea Bogoyevac - Executive Director		TIME COMPLETED:	04:00 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 Analysts (LPAs) Brian Balisi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:40am. Upon arrival LPAs met with Executive Director Lea Bogoyevac and explained the reason for the visit. The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. At approximately 10:28am, LPAs inspected (10) randomly selected bedrooms in memory care and assisted living. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed all bathrooms in each resident bedroom were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. All exits in Memory care have functioning auditory devices and were operational at the time of the visit. The LPAs observed required postings throughout the common spaces. 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.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

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: 04/15/2024

NARRATIVE

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Continued from 809

The LPAs began the inspection in the kitchen/food service area at 11:07am Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

Records review began at 12:00 PM, ten (10) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Records review revealed on 4/30/2023, Resident 1 (R1) was admitted into the facility and physician's report dated 04/28/2023, lists R1 as having no capacity for self-care which is a prohibited health condition. The licensee did not submit an exception request to admit and retain the resident with a prohibited health condition.

Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. Last emergency disaster drill was conducted 03/15/2024. All records were observed to be in order at this time.

The first aid supplies were complete , including a thermometer and a current version of a first aid manual. First aid was observed stored inaccessible in the medication cabinet as well.

Medications review began at approximately 02:00pm The medications are centrally stored in a med room on the 1st floor near the dining room. Medications are properly documented on the centrally stored medications and destruction record.

Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 04/15/2024

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	Continued from 809-C During the visit the LPAs interviewed (5) staff and (5) residents. LPAs obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance. Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3