565850299-4-10-2026-29-AS-MARO-DSZUTV-20260410155236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850299
Report Date: 04/10/2026
Date Signed: 04/10/2026 03:53:41 PM

Document Has Been Signed on 04/10/2026 03:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR/ DIRECTOR:	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: 125	DATE:	04/10/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Vanathda Dunn		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analysts (LPAs), Martha Arroyo and Brian Balisi conducted an unannounced annual inspection today at 09:15 a.m. Upon arrival, the LPAs met with Memory Care Director (MCD), Vana Dunn and explained the reason for the visit. The Executive Director (ED), Galina Tovmasian was unavailable during today’s inspection. Entrance interview.

Starting at 09:55am, the LPAs along with the MCD and Maintenance Director, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Resident Rooms / Restrooms: The LPAs observed ten (10) resident rooms in the assisted living side and three (3) resident rooms in memory care. All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:02 a.m., the hot water temperature was measured in ten (10) assisted living bathrooms and three (3) memory care bathrooms, and the temperature measured within the required range of 105 – 120 degrees Fahrenheit.

Kitchen: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPAs observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. Refrigerator and food pantry were checked for proper labels and expiration dates. The LPAs observed an adequate amount of emergency food and water; properly stored.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/10/2026

NARRATIVE

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Report Continued from LIC 809...

Common Areas: The LPAs observed common areas to be clean and in good condition. There are games and/or activity supplies in the activity rooms as well as throughout the facility. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. The LPAs observed stairwells to have emergency evacuation chairs. Emergency exiting plans/sketch are posted throughout the facility. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 11/20/2025. There were no obstructions and/or tripping hazards throughout the facility.

Outdoor Space: The LPAs observed the outdoor garden in Assisted Living and Memory Care which had shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. No bodies of water noted at the time of the visit.

Record Review: The LPAs reviewed ten (10) resident records and ten (10) staff records starting at 11:20 a.m.

Ten resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with negative TB results, consent for treatment forms, and current needs and services plan. All records were in order.

Ten personnel files including the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments with negative TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were in order.

Record review and interviews revealed that Staff #1 (S1) and Staff #2 (S2) had been working at the facility for at least 30 days but were subsequently disassociated on 01/01/2026. During today’s inspection, S1 and S2 were re-associated to the facility.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/10/2026

NARRATIVE

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Report Continued from LIC 809C...

Medication Review: The LPAs reviewed medications at approximately 11:25 a.m. The medications are centrally stored in a med room on the 1st floor near the dining room. Six (6) randomly selected resident’s medications and centrally stored medication & destruction records (CSMDR) were reviewed. Medications appear to be given as prescribed at the time of the visit.

During today’s visit, the LPAs reviewed the facility's emergency disaster plan. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 03/08/2026.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $1,000.

Exit interview was conducted. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/10/2026 03:53 PM - It Cannot Be Edited

Created By: Martha Arroyo On 04/10/2026 at 03:12 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, the Licensee did not comply with the section cited above as S1 and S2 were disassociated on 01/01/2026 but continued to work at the facility, which poses an immediate safety risk to residents in care.
	POC Due Date: 04/10/2026
	Plan of Correction
1 2 3 4	Staff were re-associated to the facility during the inspection. POC has been met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:

	Martha Arroyo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026

LIC809 (FAS) - (06/04)

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