565850299-5-10-2025-29-AS-KLOZ-DH72SU-20250530173943

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850299
Report Date: 05/10/2025
Date Signed: 05/10/2025 06:18:50 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
12/03/2024 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20241203121926

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: 135	DATE:	05/10/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Joseph Bautista, Health Services Director		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff is chemically restraining the resident.
Staff are administering the resident medication without a doctor’s prescription.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to continue investigation regarding above allegations.

Upon arrival LPA met with the Health Services Director (HSD) Joseph Bautisita and later met with the Marketing Director Amy Curtis. The reason for the visit was explained. HSD contacted the Executive Director Lea Bogoyevac and LPA spoke with ED and discussed reason for LPA's visit.

On 12/03/2024, Community Care Licensing Division received the above allegations. On 12/12/2024, LPA Brian Balisi conducted the initial complaint visit and met with Executive Director Lea Bogoyevac and reason for the visit was explained. Allegations were discussed. At approx. 2:13 p.m. LPA Balisi conducted a physical plant tour, interviewed staff and obtained copies of pertinent documentation relevant to the investigation. (Continue to LIC9099c).

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2025

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-20241203121926

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: 05/10/2025

NARRATIVE

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On 05/10/2025, from approximately 12:30pm -3pm LPA Chochian conducted additional interviews with three staff and reviewed former resident’s (R1) records including but not limited to medication and hospice records. At approximately 3pm, LPA toured the facility and conducted interview with randomly selected residents; LPA continued the tour with HCD and interviewed additional residents. Total eight (8) residents were interviewed. Also, during the tour at approximately 4pm, LPA toured the medication room and medication dispensing and recording procedures were reviewed with HCD.

Following is a summary of the allegations and investigation finding:

Allegations “Staff is chemically restraining the resident and Staff are administering the resident medication without a doctor’s prescription”. It was reported that resident #1 (R1) is being chemically restrained by the staff at the facility for financial gain. Additionally, it was reported, that on 11/17/2024 R1 was prescribed Lorazepam 3mg, and the physician was unaware of this medication change.

A review of R1’s centrally stored medication record and medication administration records conducted revealed no discrepancies. Records review revealed R1 was on hospice and the prescription for Lorazepam was 0.5mg which was prescribed by the hospice physician. Staff interviewed denied the allegations. According to staff R1 was provided care and services according to plan of care by facility staff and hospice. According to the centrally stored medication records, medication administration log and physician orders R1 was prescribed 0.5mg Lorazepam and not 3mg of Lorazepam.

Interview conducted with potential witnesses revealed that R1 was provided good care and had no issues with any of R1's medications being dispensed by facility staff or hospice nurse. Random residents interviewed expressed being satisfied with the care services and report no issues with medications dispensed.
Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff is chemically restraining the resident" and "Staff are administering the resident medication without a doctor’s prescription” are deemed Unsubstantiated at this time.

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

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2025

LIC9099 (FAS) - (06/04)

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