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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850299
Report Date: 09/30/2024
Date Signed: 09/30/2024 11:49:11 AM

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
04/19/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240419134804
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: 145DATE:
09/30/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lea Bogoyevac - Executive DirectorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Neglect/Lack of Care and Supervision: Facility Resident #1 (R1) died as a result of facility neglect.

Neglect/Lack of Care and Supervision: Staff did not provide medical attention to resident in a timely manner resulting in sepsis.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA met with Executive Director Lea Bogoyevac and explained the reason for the visit.

On 04/19/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint of two allegations of Neglect/Lack of Care and Supervision: Facility Resident #1 (R1) died due to facility neglect and staff did not provide medical attention to R1 in a timely manner resulting in sepsis. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Dennis Seng.

On 04/22/2024, from 3:50 p.m. to 5:00 p.m., LPA Balisi conducted an unannounced complaint visit for the allegations listed above. At approximately 3:50 p.m., the LPA conducted a physical plant tour, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
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 4
Control Number 29-AS-20240419134804
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: 09/30/2024
NARRATIVE
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Continued from 9099
On 07/08/2024, at approximately 4:05 p.m., Investigator Seng conducted interviews with R1’s resident representative; on 07/19/2024, from approximately 11:48 a.m. to 3:35 p.m., with Resident #2 (R2), Access TLC home health nurses and social worker, facility Executive Director/Administrator, Resident Care Coordinator, Memory Care Director, and med tech; on 08/17/2024, at approximately 4:50 p.m., with R1’s Podiatrist; on 08/30/2024, from approximately 2:48 p.m. to 3:31 p.m., with Resident Care Coordinator and med tech; on 09/03/2024, from approximately 4:21 p.m. to 4:40 p.m., with former Health Services Director and med tech; on 09/05/2024, at approximately 12:52 p.m., with Adventist Health Hospital ER physician; and on 09/06/2024, from approximately 12:52 p.m. to 12:57 p.m., with facility staff and the Long-Term Care Ombudsman (LTCO). In addition, the investigator reviewed Adventist Health Hospital medical records, Ventura County Coroner’s Report #0134-24, Access TLC Home Health records, Performance Foot and Ankle medical records, and facility file documents, including staff training in ostomy care, related to the investigation. A review of R1’s Physician’s Report, dated 09/29/2023, listed R1’s primary diagnosis as dementia, with secondary diagnoses of ataxia. R1 was noted as having an ileostomy

The Performance Foot and Ankle medical records revealed on 10/12/2023 at 2:45 p.m., the Podiatrist conducted an exam of R1’s foot. The diagnosis was listed as musculoskeletal hammertoe deformity. R1 was to return to the office in 10 weeks for at-risk foot care. Per the Department’s interview with the Podiatrist, they stated that they were responsible for assessing R1’s hammertoe and added that the odds of R1’s hammertoe leading to sepsis was unlikely. R1 had a wound on their toe that was discovered on an examination on 12/21/2023 which exposed the bone. The doctor considered amputation of R1’s toe as an option; however, decided to try and save the toe with wound care treatment. The main priority was to focus on keeping the toe from getting infected. Orders to treat the toe included covering the foot with bandages and avoiding rubbing of it against any shoes R1 would wear. The doctor stated that they were unaware of what happened after the examination; however, stated it was unlikely for R1’s toe to become septic from 12/21/2023 to the day of death on 01/23/2024.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20240419134804
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: 09/30/2024
NARRATIVE
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Continued from 9099-C
The doctor based this on their examination, as they did not believe R1’s toe condition was serious and that a wound on R1’s toe would not progress to sepsis in a month due to the poor blood supply in that area of R1’s foot. The doctor added that they had no additional concerns with the facility or R1’s condition.

According to the review of the facility logbook, on 01/23/2024 at 8:21 a.m., Resident #2 (R2) called staff to transport R1 to the bathroom. The staff attempted to move R1; however, R1 declined, as R1 preferred to remain in bed. Staff left R1 alone in their bed. At 9:13 a.m., R2 called staff and they returned to transport R1 to the toilet, and they emptied R1’s ostomy bag. The staff gave R1 water as R1 was thirsty. The staff transferred R1 to their recliner and noticed R1 appeared pale. The staff called for a med tech to come and assess R1. 911 was called and R1 was transferred to Adventist Health Hospital in Simi Valley.

According to the Adventist Health Hospital records, on 01/23/2024 at approximately 10:46 a.m., R1 was admitted for treatment for cardiac arrest. R1 was unresponsive upon arrival; per the report, R1 was transported from their bed to chair and R1’s body went limp and collapsed. The paramedics performed CPR for approximately 20 minutes prior to R1’s arrival. R1 arrived at the ER in full cardiac arrest and was pronounced dead at 10:55 a.m.. Based on the labs, R1 may have been septic, which caused R1’s cardiac arrest. The Ventura County Coroner’s report noted there was no trauma or neglect associated with the death.

On the allegation “Neglect/Lack of Care and Supervision: Facility Resident #1 (R1) died as a result of facility neglect” - Based on records review and interviews conducted, there was insufficient evidence to prove that the facility was responsible for R1’s death. Per R1’s Podiatrist, R1 sustained a hammertoe diagnosis on 12/21/2023; however, the doctor stated it was unlikely for R1’s toe to become septic from 12/21/2023 to 01/23/2024 which would lead to R1’s death.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20240419134804
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: 09/30/2024
NARRATIVE
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Continued from 9099-C
Based on the examination, the doctor did not believe R1’s toe condition was serious and added that the likelihood for R1’s toe to become septic in such a short timeline would be unlikely. The ER Physician stated that they believed R1 was septic. The physician based this on R1’s white blood cell count; however, stated that this would likely be from a UTI or pneumonia instead of neglect. The facility logbook showed that staff would check on R1 daily. They would also empty R1’s bag and change it as needed. The Coroner’s Report stated that they did not believe there was any sign of obvious trauma or neglect associated with R1’s death. Per the Access TLC home health nurses, they trained staff on how to manage R1’s ostomy bags. They did not witness any signs of neglect and believed the facility staff were adequately caring for R1. Based on the evidence received from the Coroner’s Report, ER Physician, Podiatrist, Access TLC home health nurses and their medical records, the Department did not find sufficient evidence that the facility neglected the care of R1 leading to R1’s death. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation “Neglect/Lack of Care and Supervision: Staff did not provide medical attention to resident in a timely manner resulting in sepsis.” - Based on records review and interviews conducted, there was insufficient evidence to prove that the facility was responsible for R1’s developing sepsis and passing away at the hospital due to the facility’s failure to obtain medical attention for R1. Per the med techs and direct care staff, they did not notice any change in condition with R1 in the week prior to R1’s death. The facility logs showed that staff would check on R1’s bag daily and address any bag drainages or changes as needed. Access TLC home health nurses both added they did not witness any signs of neglect when they would conduct follow up appointments with R1 to treat R1’s bag. Based on the evidence received from the facility staff, Access TLC home health nurses, and the facility logs, the Department did not find sufficient evidence that the facility was responsible for neglect leading to failure to provide proper medical attention leading to R1 getting sepsis and passing away. Therefore, the allegation is deemed Unsubstantiated at this time.

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

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4