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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850299
Report Date: 01/28/2025
Date Signed: 01/28/2025 02:20:08 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
12/18/2024 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20241218153517
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:
01/28/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lea BogoyevacTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff handled resident in a rough manner resulting in resident's injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegation. The initial visit was conducted on 12/20/2024 by LPA M. Arroyo. During today's visit, the LPA met with Executive Director (ED), Lea Bogoyevac. Entrance interview.

During the initial visit on 12/20/2024, LPA Arroyo conducted interviews with six staff and six residents, and conducted a file review and obtained copies of pertinent documents between 11:05 a.m. and 2:20 p.m.

It was alleged that staff handled resident in a rough manner resulting in resident’s injury. It was reported that staff has long nails and while bathing Resident #1 (R1), staff was aggressive and scratched R1.

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

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
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-20241218153517
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: 01/28/2025
NARRATIVE
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Report Continued from LIC 9099...

Interviews conducted with staff revealed that R1 had reported to facility staff that it hurt when they were being cleaned. However, R1 did not indicate that staff had been aggressive or rough during the assistance. After the report, R1 was assessed and tested, which resulted in a diagnosis of a urinary tract infection (UTI). No cuts, scratches, or bruising were observed on R1’s body. Additionally, the interviews with staff revealed that they follow proper hygiene protocols, such as wearing gloves and ensuring that they are gentle and patient while assisting residents. During resident interviews, residents denied any instances of staff being aggressive or rough. Furthermore, residents described the staff as nice and reported having no concerns about staff or living at the facility. Based on interviews conducted with facility staff and residents, the Department does not have sufficient evidence to support the allegation of “staff handled resident in a rough manner resulting in resident’s injury”. Therefore, this allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Report was reviewed and copy issued.

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

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2