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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850424
Report Date: 10/28/2024
Date Signed: 10/28/2024 02:32:59 PM

Document Has Been Signed on 10/28/2024 02:32 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 RANCHFACILITY NUMBER:
565850424
ADMINISTRATOR/
DIRECTOR:		LILIT E MNATSAKANYANFACILITY TYPE:
740
ADDRESS:190 TIERRA REJADA WAYTELEPHONE:
(805) 584-8881
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 100CENSUS: 70DATE:
10/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Lilit MnatsakanyanTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent unannounced Case Management - Incident visit at approx 11:00 a.m. to continue the investigation of a self-reported incident that was initially conducted  on 09/05/2024 between 12:30 p.m. - 02:30 p.m. Upon arrival LPA met with Executive Director Lilit Mnatsakanyan and explained the reason for the visit.

At approx 11:15 a.m. LPA conducted physical plant, interviewed staff, residents and reviewed and obtained copies of additional pertinent documentation relevant to the investigation.

On 08/23/2024, the Department received an incident reports stating on 08/15/2024 at approx 8am, Staff #1 (S1) was observed to be handling Resident #1(R1) in a firm manner while R1 attempted to swing their arms in an agitated manner, resulting in discoloration / bruising on R1's forearms. R1 did not indicate any discomfort or additional injuries.

Interviews conducted with staff and Executive Director revealed on 08/15/2024 at approx 8:00 a.m.  Staff #2 (S2) attempted to change R1's clothes for breakfast. R1 reacted with increased agitation and became combative towards S2. S1 entered the room to provide assistance to S2. R1's agitation and combative behavior escalated towards both staff members. S1 then restrained R1 by grasping both wrists, which led to bruising on R1's forearms. LPA's records review indicated S1 was suspended pending an investigation, both law enforcement and R1's family were notified of the incident on the same day it occurred. Additionally, S1 voluntarily resigned from their position following the incident. Based on the investigation's findings, there is sufficient evidence to conclude that S1 handled R1 in a rough manner , resulting in bruising on R1's forearms.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D).

Exit interview conducted. Copy of report and appeal rights were reviewed and issued during today's visit.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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Document Has Been Signed on 10/28/2024 02:32 PM - It Cannot Be Edited


Created By: Brian Balisi On 10/28/2024 at 01:19 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: 10/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/29/2024
Section Cited
CCR
87468.2(a)(8)

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87468.2(a)(8) To be free from neglect, financial, exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by:
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Licensee agreed to hold a training on all Personal Rights, Mandated Reporting and Abuse for all staff, provide proof of training with staff signatures to CCL via email by COB 10/29/2024.
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Based on interviews and record review the Licensee did not comply with the regulation cited above as S1 handled resident in a rough manner and caused bruising, which poses an immediate health and safety 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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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