565850424-7-14-2026-29-AS-MARO-DVYVMR-20260714163358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850424
Report Date: 07/14/2026
Date Signed: 07/14/2026 04:35:06 PM

Document Has Been Signed on 07/14/2026 04:35 PM - 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 WOOD RANCH		FACILITY NUMBER:	565850424
ADMINISTRATOR/ DIRECTOR:	KELLIE SMITH		FACILITY TYPE:	740
ADDRESS:	190 TIERRA REJADA WAY		TELEPHONE:	(805) 584-8881
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 100		CENSUS: 78	DATE:	07/14/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Kellie Smith		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

NARRATIVE

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Licensing Program Analysts (LPAs), Martha Arroyo and Valeria Conway conducted an unannounced annual inspection today. Upon arrival, the LPAs were greeted by the front desk concierge and shortly after met with Executive Director (ED), Kellie Smith, and the reason for the visit was explained. Entrance interview.

Starting at 09:55am, the LPAs along with ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Resident Rooms / Restrooms: The LPAs observed six (6) resident rooms in the Assisted Living (AL) side and two (2) resident rooms in Memory Care (MC). All resident rooms were furnished appropriately, with clean linens and appropriate furnishings. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:10 a.m., the hot water temperature was measured in eight (8) total bathrooms in both AL and MC bathrooms. Four (4) out of eight (8) bathrooms measured between 120.6 and 128.7 degrees Fahrenheit which is above the required range of 105 – 120 degrees Fahrenheit. Staff adjusted the water temperature at the time of the visit.

Kitchen: Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. The LPAs observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day supply of food and water. Refrigerator and food pantry were checked for proper labels and expiration dates. The LPAs observed an adequate amount of emergency food and water; properly stored.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/14/2026

NARRATIVE

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Report Continued from LIC 809...

Common Areas: The LPAs observed common areas to be clean and in good condition. There are games and/or activity supplies in the activity rooms. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways. The facility maintained a comfortable temperature. The LPAs observed several fireplaces throughout the facility; adequately covered. Required postings were observed throughout the common space. The LPAs observed stairwells to have emergency evacuation chairs. Emergency exiting plans/sketch are posted throughout the facility. At 10:07 a.m., the LPAs observed three (3) bottles of cleaning supplies including Lysol and disinfectant spray in the AL 2 unlocked and accessible to residents in care. Staff secured cleaning supplies at the time of the visit. Several fire extinguisher are located throughout the facility and were observed to be fully charged and last serviced on 11/11/2025. There were no obstructions and/or tripping hazards throughout the facility.

Outdoor Space: The LPAs observed the outdoor garden in Assisted Living and Memory Care which had shaded seating areas for resident use. All passageways were observed to be clear and free of hazards. No bodies of water noted at the time of the visit.

Record Review: The LPAs reviewed nine (9) resident records and eight (8) staff records starting at 12:30 p.m.

Nine resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with negative TB results, consent for treatment forms, and current needs and services plan. All records were in order.

Eight personnel files including the current Executive Director’s file were reviewed for, but not limited to: personnel records, health assessments with negative TB results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were in order.

Medication Review: The LPAs reviewed medications at approximately 02:10 p.m. The medications are centrally stored in a medication room on the 2nd floor. Four (4) randomly selected resident’s medications and centrally stored medication & destruction records (CSMDR) were reviewed. Medications appear to be given as prescribed at the time of the visit. During the visit, the facility was advised that pre-pouring residents' medications is not permitted and must be discontinued moving forward.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/14/2026

NARRATIVE

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Report Continued from LIC 809C...

During today’s visit, the LPAs reviewed the facility's emergency disaster plan. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. The last fire safety inspection was completed on 06/05/2026 and was found to be in compliance with Fire Code Regulations at the time of inspections. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 06/10/2026.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code.

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

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/14/2026 04:35 PM - It Cannot Be Edited

Created By: Martha Arroyo On 07/14/2026 at 04:10 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as four out of eight resident faucets delivered hot water between 120.6 and 128.7 degrees Fahrenheit, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2026
	Plan of Correction
1 2 3 4	The hot water temperature was adjusted at the time of the visit. POC has been cleared.

Type B

Section Cited

CCR

87309(a)

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as three disenfectant bottles were observed in AL 2 unlocked and accessible to residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2026
	Plan of Correction
1 2 3 4	The cleaning supplies were locked at the time of the visit. POC has been met.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:

	Martha Arroyo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

LIC809 (FAS) - (06/04)

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