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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850067
Report Date: 03/20/2025
Date Signed: 03/20/2025 02:51:25 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
02/12/2025 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20250212142729
FACILITY NAME:VISTA AT SIMI VALLEYFACILITY NUMBER:
565850067
ADMINISTRATOR:LEWIS, MADISONFACILITY TYPE:
740
ADDRESS:1236 ERRINGER ROADTELEPHONE:
(805) 351-8802
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:130CENSUS: 91DATE:
03/20/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Madison LewisTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not re-order incontinent supplies timely resulting in residents not having incontinent supplies

Due to lack of staff, residents are developing pressure injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with staff and explained the reason for the visit. Executive Director Madion Lewis arrived shortly after.
On 02/18/2025, the initial complaint visit was conducted by LPA between approximately 10:10 a.m. - 03:30 p.m. During the visit, LPA’s conducted physical plant, interviewed staff, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. Today LPA interviewed residents, staff and families / responsible parties of residents in care.
It was reported that "Staff do not re-order incontinent supplies timely resulting in residents not having incontinent supplies", as it was alleged that there is insufficient supply of incontinent products. Interviews conducted with eight (8) staff revealed that seven (7) out of eight (8) have always seen a sufficient supply of incontinence products available. One (1) out of the (8) staff interviewed stated they have observed some incontinent supplies to be low  approximately once or twice in the last year , but each time supplies were ordered and arrived to the facility in a timely manner.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
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-20250212142729
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: VISTA AT SIMI VALLEY
FACILITY NUMBER: 565850067
VISIT DATE: 03/20/2025
NARRATIVE
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In addition, all staff interviewed stated that when they observe any supplies to be low they inform either the med techs or management. All staff indicated that they have observed supplies to be ordered in a timely manner at this time.  During a physical plant, the LPA found a proper supply of these products in seven (7)   resident rooms in assisted living  and four (4) randomly selected bedrooms in memory care, as well as in a supply closet next to the med room and a storage room on the 2nd floor. Interviews with four (4) families / responsible parties of residents in care revealed that they did not express any immediate or potential  concerns for lack of supplies for residents at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not re-order incontinent supplies timely resulting in residents not having incontinent supplies” is deemed Unsubstantiated at this time.

It was reported that "Due to lack of staff, residents are developing pressure injuries" as it was alleged that that there have been multiple shifts with only one (1) caregiver to assist all the residents. Interviews with eight (8) staff members indicated that seven (7) have never observed a shift with only one (1) caregiver. One (1) staff member reported that, on one occasion in the past year, they worked a shift with no other caregiver for approximately two (2) hours due to staff calling out. However, during this time, they received assistance from medication technicians and at least two (2) staff members from management until additional staff were called in. LPA's  review of staff schedules showed that, typically, there are at least three (3) caregivers scheduled per shift, and on heavy shower days, four (4) caregivers are scheduled. During the NOC (night) shift, there are (3) caregivers on the floor, along with a med tech and a nurse on call. Additionally, interviews and records review revealed, that five (5) residents have been observed with pressure injuries since November 2024, but all were seen by home health or hospice care at least twice a week. Furthermore all staff indicated depending on care plan residents are repositioned or placed with proper support at least every hour. Interviews with four (4) families or responsible parties of residents in care revealed that none expressed any immediate or potential concerns about staffing or response times at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Due to lack of staff, residents are developing pressure injuries” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2