<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850299
Report Date: 10/22/2024
Date Signed: 10/22/2024 11:45:32 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
10/14/2024 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20241014190246
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: 146DATE:
10/22/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lea BogoyevacTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handled resident in a rough manner.
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 the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial complaint visit was conducted on 10/17/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Lea Bogoyevac. Entrance interview.

During the initial visit on 10/17/2024, LPA Arroyo conducted interviews with three staff and one resident between 2:15 p.m. and 3:55 p.m., conducted a file review at approximately 4:00 p.m., and obtained copies of pertinent documents.

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

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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 2
Control Number 29-AS-20241014190246
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: 10/22/2024
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 9099...

It was alleged that staff handled resident in a rough manner. It is the complainant’s concerns that two (2) caregivers were rough with Resident #1 (R1) resulting in R1 having bruises on their arms. Record review of R1’s physician’s report dated, 06/06/2024 lists R1’s primary diagnosis as osteoarthritis and mild cognitive impairment (MCI). Additionally, per R1’s preplacement appraisal information dated 04/24/2024 indicates under mental condition that R1’s short term memory is not really good. Interviews conducted with facility staff revealed that R1 has had a personal companion 24 hours a day for at least two (2) months. Staff stated that R1’s family hired a personal companion for R1 to ensure R1 was getting taken care of at all times as R1 has been alleging staff mistreatment. Additionally, per Los Robles occupational therapy evaluation dated 09/27/2024, it states “patient very verbose and requires frequent redirection”. During separate interviews conducted with R1, the LPA and complainant did not observe any bruising on R1’s arms. Furthermore, R1 was asked about the incident; however, due to R1’s inconsistency with their statements, the information obtained did not include evidence sufficient to corroborate the allegation. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff handled resident is a rough manner”. Therefore, this allegation is deemed Unsubstantiated at this time.

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

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

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2