565850299-6-5-2025-29-AS-KLOZ-DJ23ZS-20250626184202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850299
Report Date: 06/05/2025
Date Signed: 06/05/2025 02:53:09 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
10/30/2024 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20241030124951

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: 132	DATE:	06/05/2025
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Lea Bogoyevac		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Due to neglect / lack of care and supervision, resident sustained unexplained bruises while in care.
Staff do not ensure that a resident's incontinence needs are met.
Staff do not ensure that a resident's dietary needs are met.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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

On 10/30/2024, the Department received a complaint regarding allegations of Neglect / Lack of Care and Supervision.

The initial complaint visit was conducted on 10/31/2024 by LPA B. Balisi and a subsequent complaint visit was conducted on 04/22/2025 by LPA M. Arroyo.

Report Continued on LIC 809C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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 4

Control Number 29-AS-20241030124951

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: 06/05/2025

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

Report Continued from LIC 809...

During the initial visit on 10/31/2024, starting at approximately 11:15 a.m., LPA Balisi conducted a physical plant tour, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. On 04/22/2025, between 1:45 p.m. and 3:35 p.m., LPA Arroyo conducted interviews with three staff and eight residents and conducted a resident file review and obtained copies of pertinent documents.

Records reviewed and interviews conducted revealed Resident #1 (R1) was admitted to the facility on 08/16/2024. R1’s physician’s report, dated 08/16/2024, listed R1’s primary diagnosis as cerebral atherosclerosis and dementia with a secondary diagnosis of insomnia, constipations, and hyperlipidemia. R1 was identified as being confused/disoriented yet able to follow simple instructions. The report also indicates R1 requires assistance with bathing, dressing / grooming, caring for toileting needs, and managing cash resources. However, R1 is able to feed themselves. Additionally, report stated R1’s ambulatory status is non-ambulatory.

It was alleged that resident sustained unexplained bruises while in care. It was reported that R1 appeared to have a bite mark on the left hand, bruises on the legs, and a scratch on the right elbow. Records reviewed and interviews conducted revealed that R1's body is checked at least once per day, as outlined in the Resident Assessment dated 08/21/2024, which indicates that R1 has fragile skin and requires occasional skin checks. Additionally, according to R1’s Individualized Service Plan (ISP) dated 08/21/2024, R1 has experienced a fall within the past year and requires to be part of their fall management program. Staff interviews confirmed that each morning, while assisting R1, they assess R1’s skin and promptly report any changes to the medication technician or hospice staff. Staff reported that R1 tends to move frequently while lying in bed, which occasionally results in contact with the bed rails and self-inflicted scratches. However, staff denied observing any bruises on R1 that appeared intentional or caused by another person. They added that R1 is still adjusting to the bed and sometimes attempts to get up, which may contribute to the injuries. Correspondingly, Outside Provider Information (OPI) from hospice nurse visits dated 09/11/2024 documents that R1 had a skin tear on their right shin, for which the hospice nurse provided wound care.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20241030124951

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: 06/05/2025

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

Report Continued from LIC 809C...

Additionally, the OPI dated 09/30/2024 notes that the hospice nurse observed multiple areas of skin discoloration on both shins and provided wound care for skin tears on R1’s right knee and left forearm. Furthermore, the OPI dated 10/23/2024 states that R1’s wounds were healing well, the hand skin tear was scabbing, and no open wounds were present on that day. An interview with R1’s power of attorney (POA) revealed that they frequently visit R1 and expressed no concerns regarding R1’s care as facility staff has been great. Additionally, during resident interviews, no concerns were reported regarding the care provided by the facility staff. Based on the information obtained and reviewed, the Department has insufficient evidence to support the resident sustained any injuries as a result of neglect or lack of supervision. Therefore, the allegation of “resident sustained unexplained bruises while in care” is deemed Unsubstantiated at this time.

It was also alleged that staff do not ensure that a resident's incontinence needs are met. It was reported that R1 was left in a soiled diaper on 10/26/2024. Interviews conducted with staff revealed that residents are checked at least once every two (2) hours and changed as needed. Staff stated that incontinence checks are also conducted based on each resident’s level of care and individualized care plan. Residents who require full assistance are typically checked every two hours, while others are checked every two to three hours. According to Outside Provider Information (OPI) dated 08/29/2024 and 09/03/2024, a visiting hospice nurse noted that facility staff were applying prescribed skin barrier products to R1’s bottom to treat and prevent skin breakdown. Additionally, OPI dated 08/26/2024 documented that R1 verbalized to the hospice nurse that they wanted their brief changed, and facility staff were promptly called to assist. During an interview with R1’s Power of Attorney (POA), they stated that they had no concerns regarding staff changing R1 in a timely manner. In a resident interview, R1 confirmed that staff regularly check on them and reported that they are not left in wet briefs, as changes are made frequently. Other residents interviewed also did not express any concerns regarding staff appropriately addressing their incontinence needs. Furthermore, no concerns related to this issue were noted or reported on any dates, including 10/26/2024. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff do not ensure that a resident’s incontinence needs are met”. Therefore, this allegation is deemed Unsubstantiated at this time.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20241030124951

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: 06/05/2025

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

Report Continued from LIC 809C...

It was further alleged that staff do not ensure that a resident's dietary needs are met. It was reported that R1 experienced weight loss due to staff serving food but not providing assistance with feeding. Record reviewed and interviews conducted revealed that staff assist R1 during mealtimes. A review of R1’s Individualized Service Plan (ISP) dated 08/21/2024 indicates that R1 requires assistance while eating. The care plan specifies that facility staff are to provide complete assistance to Resident 1 (R1), including opening containers, cutting food, and assisting or prompting R1 to eat. According to R1’s physician’s report, R1 weighed 90 pounds upon admission to the facility. Staff interviews indicated that R1 has never refused food while residing at the facility and consistently consumes Ensure drinks when provided. Staff also reported that R1 is able to pick up and eat food independently, provided it is cut into small pieces. Additionally, staff noted that while only a few residents require direct feeding assistance, most simply need encouragement or reminders to eat. Although there is no current recorded weight for R1, staff have not reported or documented any concerns or noticeable changes regarding R1’s weight. According to Outside Provider Information (OPI) from hospice nurse visits—including, but not limited to, visits on 09/03/2024 and 10/14/2024—the hospice nurse documented positive interactions between R1 and facility staff and observed staff feeding R1. Additionally, the OPI dated 10/23/2024 noted no significant changes in R1’s condition and indicated that R1 had consumed most of their meals during the visits. Interviews conducted with randomly selected residents revealed no concerns regarding the care provided by facility staff. Interviews conducted with random residents revealed no concerns regarding the care provided by facility staff. Furthermore, during an interview with R1’s POA, it was stated that they visit R1 frequently and have observed staff assisting R1 with feeding on multiple occasions. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff do not ensure that a resident’s dietary needs are met”. Therefore, this allegation is deemed Unsubstantiated at this time.

No citations issued. Exit interview conducted. Report was reviewed and copy provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4