565850299-10-20-2025-29-AS-DPEA-DMXTP8-20251030145356

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850299
Report Date: 10/20/2025
Date Signed: 10/20/2025 02:07:17 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
06/10/2025 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20250610095737

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:	10/20/2025
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Dina Davis		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility did not meet the needs of the resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. On today's visit, LPA Arroyo met with Regional Operational Specialist (ROS), Dina Davis. Entrance interview.

On 06/10/2025, the Department received a complaint alleging facility did not meet the needs of Resident #1 (R1). It was reported that facility did not provide proper care to R1’s toe therefore, R1’s family had to hire an outside agency to provide care for R1. It was further stated that agency staff had to inform the facility staff to provide appropriate care for R1’s toe.

Report Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025

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-20250610095737

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: 10/20/2025

NARRATIVE

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Report Continued from LIC 9099...

A complaint was previously received by the department on 04/19/2024 (CC##29-AS-20240419134804), which alleged two allegations of Neglect/Lack of Care and Supervision: Resident #1 (R1) died due to facility neglect and staff did not provide medical attention to R1 in a timely manner resulting in sepsis. The complaint was referred to Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Dennis Seng at the time. On 09/30/2024, the Department unsubstantiated both allegations due to insufficient evidence.

On 06/16/2025, LPA Arroyo conducted interviews with two staff and reviewed and obtained copies of pertinent documents relevant to the investigation. Additionally, the Department’s Investigation Report for complaint #29-AS-20240419134804 related to the 01/23/2024 incident included interviews, Adventist Health Hospital medical records, Ventura County Coroner’s Report #0134-24, Access TLC Home Health records, Performance Foot and Ankle medical records, and facility file documents, including staff training.

The Department’s investigation revealed that on 01/23/2024, while R1 was being transferred from their bed to their wheelchair by facility staff, R1 became unresponsive, and 911 was called. Facility staff placed R1 on the floor and began performing compressions until paramedics arrived. R1 was then transported to the hospital and arrived at the emergency room (ER) in full cardiac arrest. According to the ER doctor who pronounced R1’s death, there was no obvious trauma or neglect associated with the death.

According to the Access TLC home health nurses, they did not observe any signs of neglect and believed that the facility staff were providing adequate care for R1. R1’s podiatrist reported that R1 was diagnosed with hammertoe on 12/21/2023; however, the doctor stated it was unlikely that the toe became septic between 12/21/2023, and 01/23/2024, leading to R1’s death. Additionally, the ER physician indicated that R1 was likely septic, based on R1’s elevated white blood cell count; however, the physician suggested that the sepsis was more likely caused by a urinary tract infection (UTI) or pneumonia, rather than neglect. Furthermore, the facility’s logbook showed that staff checked on R1 daily.

Based on the evidence obtained from complaint #29-AS-20240419134804, the Department has insufficient evidence to support the allegation that the facility failed to meet the needs of the resident in care. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview. Report was reviewed and copy issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025

LIC9099 (FAS) - (06/04)

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