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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850299
Report Date: 12/20/2024
Date Signed: 12/20/2024 03:35:05 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
12/17/2024 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20241217102437
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: 142DATE:
12/20/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lea BogoyevacTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not ensure facility was free from pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint investigation visit for the above allegation. Upon arrival, the LPA met with Executive Director (ED), Lea Bogoyevac and explained the reason for the visit. Entrance interview conducted.

During today's visit, between 11:05 a.m. and 2:45 p.m., the LPA conducted interviews with six staff, seven residents, and one private companion, observed Resident #1’s (R1’s) apartment, and conducted a file review 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: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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-20241217102437
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: 12/20/2024
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff did not ensure facility was free from pests. It was reported that R1’s is being bitten by earwigs in their room. During the visit, the LPA conducted a walkthrough inside R1's apartment and did not observe any signs of bugs. Record reviews and interviews revealed that R1 had reported seeing earwigs inside their apartment. Staff stated that R1’s room had been inspected by several facility staff members to ensure there were no bugs or earwigs present. A record review of staff communication, dated 12/09/2024, indicated that the maintenance director had also inspected R1’s room and reported no bugs of any kind. Additional records show that the facility receives monthly pest control services from Ecolab to maintain a bug-free environment. Interviews further revealed that R1 has been consistently mentioning bugs, specifically earwigs, over the past couple of weeks, although staff have attempted to redirect R1, as they have not observed any bugs in R1’s bedroom. Furthermore, five out of five residents interviewed denied seeing any bugs while living at the facility and reported no concerns regarding pests. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not ensure facility was free from pests”. Therefore, this allegation is deemed Unsubstantiated at this time.

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

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

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2