565850299-5-8-2025-29-AS-KLOZ-DGWVKF-20250522163016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850299
Report Date: 05/08/2025
Date Signed: 05/08/2025 02:51:10 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
08/13/2024 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20240813132042

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: 142	DATE:	05/08/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Lea Bogoyevac		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff did not meet hygiene needs of residents.
Facility staff did not ensure residents had clean clothing.
Facility staff did not dispense medications to residents as prescribed.
Facility staff did not respond to resident's call in a timely manner.
Facility staff did not check resident’s blood pressure as required.
Facility staff did not meet resident's incontinence care needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegations. On today’s visit, the LPA met with Executive Director (ED) Lea Bogoyevac and explained the reason for the visit. Entrance interview.

The initial visit was conducted on 08/15/2024 and a subsequent visit was conducted on 04/22/2025, both by LPA M. Arroyo. On 08/15/2024, the LPA conducted interviews with the ED and two staff members between 10:25 a.m. and 1:15 p.m., conducted a file review at 11:30 a.m., conducted a medication review of two randomly selected residents 1:30 p.m., and obtained copies of pertinent documents. On 04/22/2025, the LPA conducted interviews with three staff and eight residents, conducted a medication review, conducted a resident file review and obtained copies of pertinent documents between 1:45 p.m. and 3:35 p.m.

Report Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

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 7

Control Number 29-AS-20240813132042

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: IVY PARK AT SIMI VALLEY	FACILITY NUMBER: 565850299
	VISIT DATE: 05/08/2025

NARRATIVE

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Report Continued from LIC 9099...

Records review and interviews conducted revealed Resident #1 (R1) was admitted to the facility on 10/28/2017. Per R1’s physician’s report dated 04/25/2022, it lists R1’s primary diagnosis as mild cognitive impairment (MCI), is able to follow instructions and communicate needs. The report indicates R1 is able to bathe, dress/groom, feed self, care for own toileting needs, and manage own cash resources. Additionally, per doctor’s orders, R1’s blood pressure is checked every other day scheduled for Monday, Wednesday, and Friday at 9:00 a.m. Also, Resident #2 (R2) was admitted to the facility on 05/25/2023 and per physician’s report dated 05/27/2024, R2 is able to follow instructions and communicate needs. Review of R2’s assessment dated 05/27/2024 states R2 requires assistance setting up grooming tools, hands on assistance with dressing / undressing, escorting to meals and activities, showering / bathing 1-2 times a week, occasional incontinent assistance, is a high fall risk, and requires vital sign checks 1 time a day, per physician’s order.

It was alleged that facility staff did not meet hygiene needs of residents and facility staff did not ensure residents had clean clothing. It was reported that residents are not getting their showers and clothes were dirty and appeared to not have been changed for several days. Records reviewed and interviews with staff revealed that housekeeping is done daily, and each resident’s laundry is scheduled to be done once a week. However, caregivers will use washers and dryers that are located throughout the facility to do small loads if for any reason a resident requires clean clothes or linens. Additionally, staff stated that residents are assisted with all activities of daily living (ADLs) depending on their care plan. If a resident is not able to shower / bathe or dress / groom themselves, the staff will assist the resident to ensure the resident is getting their needs met. Additionally, R1 is able to shower / bathe themselves without needed assistance from staff and R2 is on a shower rotation indicating R2 is currently getting assistance with showers / bathing on the evenings of Monday’s, Wednesday’s, and Saturday’s. Furthermore, interviews conducted with residents revealed that staff will assist them at any time when they request assistance and reported no concerns living at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegations of “facility staff did not meet hygiene needs of residents” and “facility staff did not ensure residents had clean clothing.” Therefore, this allegation is deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 29-AS-20240813132042

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: IVY PARK AT SIMI VALLEY	FACILITY NUMBER: 565850299
	VISIT DATE: 05/08/2025

NARRATIVE

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Report Continued from LIC 9099C...

It was also alleged that facility staff did not dispense medications to residents as prescribed. It was reported that staff have administered medications to the wrong residents and have occasionally failed to administer medications. Medication reviews conducted on 08/15/2024 and 04/22/2025 revealed that medications were properly documented on the Centrally Stored Medication and Destruction Records (CSMDR) and appeared to be administered as prescribed at the time of inspection. Interviews with staff indicated that med-techs assist residents with medication administration. Med-techs either bring medications to residents in their rooms or meet them in common areas where they are known to be at the scheduled time. Additionally, many ambulatory and fully alert residents independently go to the medication room to receive their medications. Furthermore, interviews conducted with residents confirmed that they receive their medications daily as prescribed and reported no concerns regarding their medication administration. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “facility staff did not dispense medications to residents as prescribed”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was also alleged that facility staff did not respond to resident's call in a timely manner and facility staff did not check resident’s blood pressure as required. It was reported that facility staff did not respond to a resident’s request for assistance in taking their blood pressure when they were not feeling well. Records reviewed and interviews conducted revealed that certain residents have doctors' orders to monitor their blood pressure regularly. According to the electronic medication administration records (eMAR) for Residents R1 and R2, both residents had their blood pressure monitored in accordance with their respective physician’s orders. R1's blood pressure was checked every other day, while R2's was checked every morning. Additionally, interviews with R1 and R2 confirmed that staff assist them with blood pressure monitoring as needed, and both residents stated they have no issues requesting help from staff. R1 also added that they had asked staff to take their blood pressure on several occasions, and staff never refused. Interviews with randomly selected residents further revealed that they frequently use their call pendants to request assistance and reported no issues with staff response times. Residents also noted that staff are consistently willing to help and routinely check on them throughout the day to ensure their well-being. Furthermore, residents expressed no concerns regarding staff responsiveness, or the assistance provided.

Report Continued on LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 29-AS-20240813132042

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: IVY PARK AT SIMI VALLEY	FACILITY NUMBER: 565850299
	VISIT DATE: 05/08/2025

NARRATIVE

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Report Continued from LIC 9099C...

Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegations of “facility staff did not respond to resident’s call in a timely manner” and “facility staff did not check resident’s blood pressure as required”. Therefore, these allegations are deemed Unsubstantiated at this time.

It was further alleged that facility staff did not meet resident's incontinence care needs. It was reported that residents are left soaking wet for hours, especially during the nighttime. Interviews conducted with staff revealed that residents are checked for incontinence based on their level of care and care plan. Full-assist residents are typically checked at least once every two hours, while others are checked every two to three hours. Staff stated that residents are separated into sections, and each staff member is assigned specific areas to check and assist residents with their incontinence needs. Additionally, staff members emphasized that they ensure all residents are changed promptly, as they aim to prevent urinary tract infections (UTIs) and the development of pressure sores. Interviews conducted with residents revealed that staff frequently check on them, and residents reported that they are not left in soiled diapers. Staff members consistently ensure that residents stay dry throughout the day. Furthermore, residents did not express any concerns about staff meeting their incontinence needs. Based on interviews conducted with staff and residents, the Department has in sufficient evidence to support the allegation of “facility staff did not meet the resident’s incontinence care needs”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report was reviewed and copy provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 7

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
08/13/2024 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20240813132042

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: 142	DATE:	05/08/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Lea Bogoyevac		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff yelled in the presence of residents.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

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

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 29-AS-20240813132042

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: IVY PARK AT SIMI VALLEY	FACILITY NUMBER: 565850299
	VISIT DATE: 05/08/2025

NARRATIVE

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Report Continued from LIC 9099...

It was alleged that facility staff yelled in the presence of residents. It was reported that a staff member was observed screaming and cursing at another staff member on the evening 08/12/ 2024, while residents were present. Interviews conducted with staff revealed that medication technicians are placed in charge when management is not present in the facility. Staff reported that an altercation occurred between the medication technician and a caregiver, during which one staff member verbally attacked the other. Interviews further revealed that confrontation between staff was observed by a resident’s bedroom with the resident present, in the common areas by the dining room, and outside in the parking lot. Furthermore, a family member was entering the facility at the time, and several residents lounging in the lobby witnessed the verbal altercation between the staff members. Based on the information obtained during the course of the investigation, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation of “facility staff yelled in the presence of residents” is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 29-AS-20240813132042

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: IVY PARK AT SIMI VALLEY	FACILITY NUMBER: 565850299
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/08/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 05/12/2025 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1(a)(1) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee has agreed to have a staff training on resident’s personal rights and submit proof to CCL no later than POC due date.
	8 9 10 11 12 13 14	Based on information obtained and reviewed, including interviews, the Licensee did not comply with the section cited above as facility staff were observed yelling in the presence of residents, which poses a potential personal rights risk to residents in care.	8 9 10 11 12 13 14	POC has been met.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC9099 (FAS) - (06/04)

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