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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850299
Report Date: 05/19/2025
Date Signed: 05/19/2025 03:10:32 PM

Substantiated


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
05/24/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240524163713
FACILITY NAME:IVY PARK AT SIMI VALLEYFACILITY NUMBER:
565850299
ADMINISTRATOR:BOGOYEVAC, LEAFACILITY TYPE:
740
ADDRESS:5300 E. LOS ANGELES AVE.TELEPHONE:
(805) 583-3500
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:175CENSUS: 160DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not provide medical attention to resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with Executive Director Lea Bogoyevac and explained the reason for the visit.
On 05/30/2024, the initial complaint visit was conducted by LPA between approximately 09:45 a.m. - 03:30 p.m. During the visit, LPA’s conducted physical plant, interviewed residents, staff as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 09/30/2024, between approximately 09:45 a.m. – 03:00 p.m. LPA conducted a subsequent visit to interview staff as well as review and obtained additional pertinent documentation relevant to the investigation. On 01/30/2025, LPA conducted a subsequent visit to interview staff, families / responsible parties of residents in care as well as review and obtained copies of additional pertinent documentation relevant to the investigation. Today LPA interviewed staff and reviewed documentation pertinent to the investigation.
It was reported that "Staff did not provide medical attention to resident in a timely manner" as it was alleged that a pain patch was not changed in a timely manner.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
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-20240524163713
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: 05/19/2025
NARRATIVE
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Interviews and a review of records showed that Resident 2 (R2) was prescribed a Fentanyl 50 mcg/hour transdermal patch, with instructions to apply one patch topically every 72 hours. Records indicate that the patch was applied on 05/07/2024 at 8:00 a.m., and again on 05/10/2024 , at 8:00 a.m. R2 was admitted to a local hospital on 05/12/2024, and returned to the facility at approximately 9:45 p.m. that same day. There is no documentation showing that the patch was replaced on 05/13/2024, as would have been scheduled based on the prescribed 72-hour cycle. However, records do indicate that the patch was replaced on 05/16, 05/19 and 05/22 each at 8:00 a.m. Staff interviews did not confirm whether the patch was replaced on 05/13/2024. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation above. Therefore, the allegation "Staff did not provide medical attention to resident in a timely manner" has been deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20240524163713
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: 05/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/20/2025
Section Cited
CCR
87465(a)(4)
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The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Licensee agreed to review section cited and provide a statement of understanding along with a plan of how they will ensure future compliance then send to LPA via email by COB 05/20/2025.
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Based on interviews and record review, the licensee did not comply with the section cited above, as the facility staff could not provide confirmation that R2’s pain patch was replaced as prescribed, which poses an immediate health and safety risk to residents in care.
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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: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 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
05/24/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240524163713

FACILITY NAME:IVY PARK AT SIMI VALLEYFACILITY NUMBER:
565850299
ADMINISTRATOR:BOGOYEVAC, LEAFACILITY TYPE:
740
ADDRESS:5300 E. LOS ANGELES AVE.TELEPHONE:
(805) 583-3500
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:175CENSUS: 160DATE:
05/19/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lea BogoyevacTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained pressure injury while in care.
Staff did not rotate and repositioned resident.
Lack of supervision resulting in resident falling causing injuries.
Staff does not assist resident with daily needs.
Staff not checking resident’s blood pressure as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with Executive Director Lea Bogoyevac and explained the reason for the visit.

On 05/30/2024, the initial complaint visit was conducted by LPA between approximately 09:45 a.m. - 03:30 p.m. During the visit, LPA’s conducted physical plant, interviewed residents, staff as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 09/30/2024, between approximately 09:45 a.m. – 03:00 p.m. LPA conducted a subsequent visit to interview staff as well as review and obtained additional pertinent documentation relevant to the investigation.

On 01/30/2025, LPA conducted a subsequent visit to interview staff, families / responsible parties of residents in care as well as review and obtained copies of additional pertinent documentation relevant to the investigation. Today LPA interviewed staff and reviewed documentation pertinent to the investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20240524163713
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: 05/19/2025
NARRATIVE
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It was reported that "Resident sustained pressure injury while in care" and "Staff did not rotate and repositioned resident" as it was alleged that Resident #1 (R1) sustained pressure injuries due to staff neglect and failing to rotate and reposition R1. Interviews conducted and records review revealed R1 was admitted into the facility on 05/24/2023. LPA's records review of hospice records dated from 06/24/2023 - 01/26/2024, revealed R1 was serviced by Hospice at least two (2) times a week for routine services such as showering and to observe wound on left ankle. Records reviewed from 01/29/2024, revealed R1 was observed with Stage III pressure injury on coccyx. The records did not indicate any concerns for facility staff not repositioning R1 in a timely manner at this time. LPA's interview with six (6) staff who worked often with R1 confirmed R1 was checked on at least every (2) hours. When R1 was observed by staff it would typically involve, observing any bandages, ensuring they were dry, elevate their legs if necessary and address any concerns the R1 might express. Each staff did not express any concerns for staff not repositioning R1 in a timely manner at this time. LPA's interview with the spouse of R1, Resident #2 (R2), revealed that they have observed staff check on R1 throughout the day and reposition R1 in a timely manner. R2 did not express any concerns for staff not repositioning R1 in a timely manner at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Resident sustained pressure injury while in care" and "Staff did not rotate and repositioned resident" is deemed Unsubstantiated at this time.

It was reported that "Lack of supervision resulting in resident falling causing injuries" as it was alleged that R2 was allowed to walk out of the facility without supervision resulting in a fall. LPA records review of R2's Physician’s Report dated 06/11/2024 indicated that R2 is able to leave the facility without assistance and does not require staff support for ambulation. LPA's interview with revealed that R2 requested to go outside, and there was no indication that R2 required staff assistance or was restricted from doing so. In an interview with R2, they stated they felt well enough to go outside for fresh air. R2 reported that while walking, they were not paying attention and tripped over the uneven space between the grass and the cement walkway. R2 recalled that bystanders and an off-duty employee assisted them in getting up. The off-duty employee then accompanied R2 back into the facility, where R2 received first aid. R2 did not express any concerns regarding staff supervision, noting that they exited the facility independently and the fall occurred due to their own inattention. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20240524163713
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: 05/19/2025
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Lack of supervision resulting in resident falling causing injuries" is deemed Unsubstantiated at this time.

It was reported that "Staff does not assist resident with daily needs" as it was alleged that staff refused to assist R2 with showering, dressing and overall care. Records review and interviews confirmed that R2 was admitted to the facility on 05/24/2023. According to R2’s Individualized Service Plan (ISP) dated 05/27/2024, R2 requires hands-on assistance with the following: Dressing and grooming – Caregivers are responsible for setting up grooming materials and assisting as needed, Bathing – Caregivers provide hands-on assistance for all showering/bathing needs, scheduled 1 to 2 times per week and Toileting – R2 is occasionally incontinent and may require staff assistance with toileting. LPA's interview with R2 revealed that staff consistently assist with their daily needs. R2 confirmed receiving showers at least twice weekly and stated that staff greet them each morning, help select clothing, and escort them to meals. R2 did not express any concerns regarding the level or timeliness of staff assistance. Additionally, a review of facility records and staff interviews confirmed that residents are provided care in accordance with their individual care plans. LPA also interviewed seven (7) residents currently residing in the facility. All residents interviewed stated they had no concerns about staff assistance with daily needs. Each resident also confirmed that staff respond to requests for help in a timely manner. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation "Staff does not assist resident with daily needs" is deemed Unsubstantiated at this time

It was reported that "Staff not checking resident's blood pressure as required" as it was alleged that staff did not check R2's blood pressure twice daily as prescribed. Interviews conducted and records review revealed, on 04/16/2024, R2 received an order to "Check blood pressure twice a day through 05/08/2024 - keep log of readings" . LPA's records review revealed that from 04/16/2024 to 05/08/2024, R2's blood pressure was typically checked twice a day—once in the morning between 7:30 a.m. and 11:00 a.m., and once in the evening between 5:00 p.m. and 6:00 p.m. Additionally, on 05/20/2024, a prescription was issued for R2 to have their blood pressure checked daily. Records reviewed from 05/20/2024 to 06/02/2024, revealed R2’s blood pressure was generally checked around 8:00 a.m. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20240524163713
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: 05/19/2025
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff not checking resident's blood pressure as required “ is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7