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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850299
Report Date: 09/24/2024
Date Signed: 09/24/2024 10:45:59 AM


Document Has Been Signed on 09/24/2024 10:45 AM - 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 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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lea BogoyevacTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20231208092110). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation.

During the visit on 12/12/2023, interviews conducted with staff revealed that Resident #1 (R1) was independent and did not require assistance of daily living (ADL’s) and managed their own medications. Staff stated that R1 had their personal vehicle while living at the facility which R1 used when leaving the facility unassisted. Record review of R1’s physician report dated, 08/23/2023, indicated R1 is able to follow instructions and communicate their needs. However, physician report also indicated that R1 was not able to leave the facility unassisted and required assistance with ADL’s including but not limited to bathing, dressing/grooming self, and with toileting needs.

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.

Although this is a basic services violation, it has already been cited under the Complaint Control # 29-AS-20231208092110.

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

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
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.

LIC809 (FAS) - (06/04)
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