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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850299
Report Date: 09/24/2024
Date Signed: 09/24/2024 10:42:45 AM

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
12/08/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20231208092110
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: 145DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lea BogoyevacTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not prevent covid outbreak.
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 allegations. The initial complaint visit was conducted on 12/12/2023 by LPA M. Arroyo, and subsequent complaint visits were conducted on 04/15/2024 by LPAs M. Arroyo and B. Balisi and on 04/15/2024 and 07/29/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Lea Bogoyevac. Entrance interview.

During the initial visit on 12/12/2023, LPA Arroyo conducted interviews with the ED at 2:25pm and one staff at 2:30pm, conducted a file review at 2:55pm, and obtained copies of pertinent documents relevant to the investigation. On 04/14/2024, LPAs Arroyo and Balisi conducted five staff interviews between 12:10pm and 2:00pm and obtained copies of pertinent documents. On 07/29/2024, LPA Arroyo conducted interviews with two staff and nine residents between 1:22pm and 3:35pm and obtained copies of pertinent documents.

Report Continued on LIC 9099...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
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 6
Control Number 29-AS-20231208092110
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: 09/24/2024
NARRATIVE
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Report Continued on LIC 9099C...

It was alleged that staff did not prevent covid outbreak. It was reported that there was a covid outbreak at the facility, but it was not disclosed to family members until after 12/07/2023. Records review and interviews conducted revealed the facility had their first resident test positive for covid on 12/02/2023. Following the first positive case, the facility began testing residents that reported not feeling well or displaying signs of weakness. In December 2023, the facility reported about forty (40) residents that had tested positive not including facility staff. Records review further revealed that facility had started reporting the positive cases to Ventura Public Health (VPH) on 12/03/2023. Personal Protection Equipment (PPE) carts were being placed in residents front doors and staff were monitoring residents and doing frequent checks. Interviews conducted with staff revealed that residents were encouraged and provided PPE when coming outside of their bedrooms and into common areas. Furthermore, although the facility had a covid outbreak, the facility was reporting to the proper agencies and family members as well as taking the necessary precautions to minimize the spreading. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not prevent covid outbreak”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report was reviewed and copy was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
12/08/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20231208092110

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: 145DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lea BogoyevacTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff neglected to check on resident resulting in multiple injuries.
Staff did not ensure resident’s call button was working.
Staff did not assist resident in a timely manner.
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 allegations. The initial complaint visit was conducted on 12/12/2023 by LPA M. Arroyo, and subsequent complaint visits were conducted on 04/15/2024 by LPAs M. Arroyo and B. Balisi and on 04/15/2024 and 07/29/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Lea Bogoyevac. Entrance interview.

During the initial visit on 12/12/2023, LPA Arroyo conducted interviews with the ED at 2:25pm and one staff at 2:30pm, conducted a file review at 2:55pm, and obtained copies of pertinent documents relevant to the investigation. On 04/14/2024, LPAs Arroyo and Balisi conducted five staff interviews between 12:10pm and 2:00pm and obtained copies of pertinent documents. On 07/29/2024, LPA Arroyo conducted interviews with two staff and nine residents between 1:22pm and 3:35pm and obtained copies of pertinent documents.

Report Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20231208092110
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: 09/24/2024
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff neglected to check on resident resulting in multiple injuries and staff did not assist resident in a timely manner. It was reported that although Resident #1 (R1) is fairly independent, staff did not check on R1 for at least two (2) days. Additionally, R1 sustained bruises, sores, and scabs after falling due to R1 experiencing a fall. Furthermore, R1 called out for assistance but no one came. Information obtained during the course of the investigation revealed that R1 was admitted to the facility on 08/24/2023. Per R1’s physician report, dated 08/23/2024, it listed R1’s primary diagnosis as spinal stenosis and indicated R1 was able to follow instructions and communicate needs; however, required assistance with certain activities of daily living (ADL’s) such as bathing, dressing/grooming, and caring for toileting needs. Interviews conducted with staff revealed that all residents residing in assisted living have status checks conducted at least once per day. Staff stated that caregivers are assigned a “block” which is a list of residents that they are in charge of caring and making sure their needs are met for the duration of their shift. Staff interviews further revealed that residents that did not require assistance with ADL’s, had not had any recent falls or change in condition did not receive status checks, but were still checked on once a day. Additionally, staff stated that dining room staff usually report to caregivers if they did not see a particular resident during mealtimes. However, during December 2023, the facility had a covid outbreak which resulted staff to be understaffed, working double shifts, and they did not notice R1 had not been down at the dining room during meals. Additionally, per incident report submitted by the facility on 12/08/2023, it stated that on 12/06/2023, at approximately 2:00pm, staff was doing rounds and R1 was observed on the floor in their room, in pain and with a skin tear with discoloration to their left arm. Furthermore, during staff interviews, staff were unable to say or determine if R1 had been checked on a daily basis two (2) days prior to the unwitnessed fall incident. Based on the information obtained and reviewed, the allegation of “staff neglected to check on resident resulting in multiple injuries” in being deemed Substantiated at this time.

It was also alleged that staff did not ensure resident’s call button was working. It was reported that R1 pushed their call button pendant, but the pendant did not work. Records review and interviews conducted revealed that R1’s pendant did not activate requesting assistance prior to being checked on by staff on 12/06/2023.

Report Continued on LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20231208092110
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: 09/24/2024
NARRATIVE
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Report Continued from LIC 9099C...

Interviews conducted with staff revealed that R1 was independent and did not require assistance with ADL’s or medication management. Staff stated that residents are given a pendant which they carry at all times; as well as having a call button / pull chord available in their bathrooms. Staff also reported that periodically pendants will go out and facility will either replace batteries or entire pendant. Furthermore, staff stated that R1 had reported pressing the call button calling for help after suffering the fall. Additional records review of Device Activity Report, dated 11/30/2023 to 12/07/2023, lists the resident name and room number in which a pendant was activated and the time it took staff to respond to the call. Per report dated 12/06/2023, it took approximately two (2) hours for facility staff to report that the pendant was functioning correctly as the pendant for R1 was not tested or activated until 3:59pm on 12/06/2023. According to incident report dated 12/06/2023, R1 was found on the floor at approximately 2:00pm. Based on the information obtained and reviewed, the allegation of “staff did not ensure resident’s call button was working” is being 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: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20231208092110
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: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/30/2024
Section Cited
HSC
1569.312(a)
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1569.312(a) Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2.

This requirement is not met as evidenced by:
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Licensee agreed to submit a plan on how they will ensure appropriate care and supervision to meet the needs of residents and submit to CCL on or before POC due date.
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Based on interviews and records review, the licensee did not comply with the section cited above as staff did not check on R1 in a timely manner resulting in R1 sustaining multiple injuries, which posed an immediate health and safety risk to residents in care.
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Request Denied
Type B
09/30/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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Licensee agreed to have an in-service with staff regarding answering call pendants / pull chords in a timely manner and submit proof to CCL on or before POC due date.
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Based on record review and interviews, the licensee did not comply with the section cited above as facility staff did not ensure that resident’s call pendant for assistance was functioning properly, which posed a potential 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: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6