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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850424
Report Date: 06/09/2026
Date Signed: 06/09/2026 03:15:17 PM

Substantiated


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
06/08/2026 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20260608101601
FACILITY NAME:IVY PARK AT WOOD RANCHFACILITY NUMBER:
565850424
ADMINISTRATOR:KELLIE SMITHFACILITY TYPE:
740
ADDRESS:190 TIERRA REJADA WAYTELEPHONE:
(805) 584-8881
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:100CENSUS: 85DATE:
06/09/2026
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Kellie SmithTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are mistreating a resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival at approx 12:20 p.m. LPA met with Executive Director Kellie Smith and explained the reason for the visit.

At approx 12:30 p.m. LPA conducted physical plant, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation.

It was reported that "Staff are mistreating a resident in care" as it was alleged that staff purposefully placed ketchup on Resident #1 (R1)'s clothing , body and personal items to persuade R1 to get out of bed and change their clothes. Interviews and record reviews revealed that Staff #1 (S1) admitted to placing ketchup on R1's body, clothing, bedding, and personal belongings in an effort to encourage R1 to change clothes and prepare for the day.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026
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 3
Control Number 29-AS-20260608101601
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 WOOD RANCH
FACILITY NUMBER: 565850424
VISIT DATE: 06/09/2026
NARRATIVE
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S1 stated that, upon reflection, they exercised poor judgment in using this method. S1 further stated that they used this method on one other occasion with R1 but could not recall the exact date. S1 reported that they did not use this method with any other residents in care and they did not inform their direct supervisor or management. Interviews and record reviews further revealed that Staff #2 (S2) was aware that S1 was using ketchup with R1 for this purpose.

LPA's interview with  Executive Director stated they had spoken with R1's family member/responsible party, who reported being aware that staff were using this method because R1 had previously refused multiple attempts by staff to assist with changing clothes. According to the Executive Director , the family member/responsible party stated they did not believe staff had malicious intent and had previously discussed the method with staff.

Executive Director  further stated they were not aware of any prior discussions between S1 and the family member/responsible party regarding the use of ketchup.  In addition, the Executive Director informed the family member/responsible party that alternative redirection and intervention techniques could have been utilized instead of intentionally soiling R1's clothing.

LPA interviewed three staff members who regularly work in the area where R1 resides. These staff members stated they had not observed other residents being intentionally soiled with food or otherwise treated in an inappropriate manner. Based on the information obtained during the investigation, the allegation of  "Staff are mistreating a resident in care" has been substantiated at this time. 

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Executive Director was  informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20260608101601
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 WOOD RANCH
FACILITY NUMBER: 565850424
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2026
Section Cited
CCR
87468.1(a)(3)
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To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by:
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Licensee representative stated that staff had been suspended and written up, then returned to work after internal investigation had completed. Additionaly Licensee rep agreed to review section cited and provide a written plan to ensure future compliance then send to LPA via email by COB POC date.
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Based on interviews and records review, the licensee did not comply with the section cited above, as staff intentionally placed ketchup on R1's body and personal belongings to encourage a clothing change, which posed a potential health, safety, and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026
LIC9099 (FAS) - (06/04)
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