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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850424
Report Date: 04/09/2026
Date Signed: 04/09/2026 02:54:48 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
05/15/2025 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20250515145455
FACILITY NAME:IVY PARK AT WOOD RANCHFACILITY NUMBER:
565850424
ADMINISTRATOR:LILIT E MNATSAKANYANFACILITY TYPE:
740
ADDRESS:190 TIERRA REJADA WAYTELEPHONE:
(805) 584-8881
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:100CENSUS: 85DATE:
04/09/2026
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Kellie Smith - Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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NEGLECT/LACK OF CARE AND SUPERVISION – A facility resident was found to have
toxic levels of a medication in their system by doctors


INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegations listed above. Upon arrival, LPA met with Executive Director Kellie Smith and explained the reason for the visit.

On 05/15/2025, the Regional Office (RO) received a complaint alleging the neglect / lack of care and supervision of a resident. It was reported that Resident #1 (R1) was sent to the Emergency Room (ER) for rash / blisters. It was reported that, while at the hospital, it was discovered that “Depakote” medication in which R1 was taking was found to be at toxic levels in R1’s system. On 05/16/2025, the RO referred the case to Community Care Licensing Divisions (CCLDs) Investigations Branch (IB).

On 05/16/2025 between 10:00 a.m. to 03:30 p.m., LPA Balisi conducted the initial 10- day complaint visit. At approx. 10:00 a.m. LPA conducted physical plant tour, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
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 6
Control Number 29-AS-20250515145455
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: 04/09/2026
NARRATIVE
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Continued from 9099

On 06/11/2025, medical records from Adventists Health – Simi Valley were reviewed. Between 07/07/25 and 09/15/25, The Department interviewed current and former facility staff, R1’s Responsible Party (RP) and other relevant parties. R1’s charting notes covering periods from 01/28/25 through 07/06/25 were also reviewed. On 11/26/2025 between 09:30 a.m. to 12:30 p.m., LPA Balisi conducted a subsequent complaint visit. At approx. 09:45 a.m. LPA conducted physical plant tour, interviewed staff and reviewed and obtained additional copies of pertinent documentation relevant to the investigation.

It was reported that due to neglect/ lack of care and supervision R1 had toxic levels of a prescribed medication identified by medical providers. Interviews conducted and records review revealed that R1 was transported to the hospital on 04/21/2025 for evaluation of a skin rash and blistering. During that hospitalization, medical staff identified toxic levels of the prescribed medication Depakote in R1’s system. Hospital discharge instructions directed that Depakote be held, pending follow-up with R1’s primary care provider. Upon R1’s return to the facility, the discharge instructions were provided to facility staff by R1’s family and private caregiver, and staff were verbally informed of the medication hold. On 05/14/2025, R1 was again transported to the hospital, at which time laboratory results showed Depakote levels that were higher than those recorded on 04/21/2025. A review of facility medication records indicated that on 04/28/2025, staff began administering a newly prescribed medication, Keppra, but did not discontinue Depakote as directed in the hospital discharge instructions. As a result, from 04/28/2025 through 05/14/2025, R1 received both Depakote and Keppra. Based on the information obtained during the investigation, the allegation of neglect / lack of care and supervision, related to the continued administration of a medication that had been ordered to be held, has been deemed 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: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20250515145455
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: 04/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2026
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical&Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility… (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Licensee agreed to conduct medication inservice review section cited and create 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 continued to administer a medication to R1 that was discontinued by R1’s PCP which posed 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
05/15/2025 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20250515145455

FACILITY NAME:IVY PARK AT WOOD RANCHFACILITY NUMBER:
565850424
ADMINISTRATOR:LILIT E MNATSAKANYANFACILITY TYPE:
740
ADDRESS:190 TIERRA REJADA WAYTELEPHONE:
(805) 584-8881
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:100CENSUS: 85DATE:
04/09/2026
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Kellie Smith - Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Due to lack of supervision, resident fell resulting in a bruise

Staff did not notify authorized representative of bruise on resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegations listed above. Upon arrival, LPA met with Executive Director Kellie Smith and explained the reason for the visit.
On 05/16/2025 between 10:00 a.m. to 03:30 p.m., LPA Balisi conducted the initial 10- day complaint visit. At approx. 10:00 a.m. LPA conducted physical plant tour, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. On 06/11/2025, medical records from Adventists Health – Simi Valley were reviewed. Between 07/07/25 and 09/15/25, The Department interviewed current and former facility staff, R1’s Responsible Party (RP) and other relevant parties. R1’s charting notes covering periods from 01/28/25 through 07/06/25 were also reviewed. On 11/26/2025 between 09:30 a.m. to 12:30 p.m., LPA Balisi conducted a subsequent complaint visit. At approx. 09:45 a.m. LPA conducted physical plant tour, interviewed staff and reviewed and obtained additional 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: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20250515145455
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: 04/09/2026
NARRATIVE
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It was reported that “Due to lack of supervision, resident fell resulting in a bruise” as It was alleged that Resident 1 (R1) sustained a bruise to the abdomen as a result of a fall. Interviews conducted and records reviewed reflected that that R1 experienced a fall on 04/27/2025. On 05/09/2025, staff observed a bruise on the right side of R1’s abdomen. No fall involving R1 was documented on 05/09/2025, and R1 was unable to identify how the bruise occurred. A review of facility records indicated that no additional falls involving R1 were documented between 04/27/2025 and 05/09/2025.LPA’s interview with Staff revealed that, based on the circumstances of the fall on 04/27/2025, the observed bruise did not appear consistent with that fall. Staff reported that following the fall, R1 were found lying on their back with their head on a pillow and were not positioned against or in contact with any object at the time they were found. It was further revealed that R1 uses a scooter and has been observed leaning forward onto the scooter handles. Staff also stated that the bruise may have resulted from contact with two exposed metal poles on an attachable bed rail when the rail is in the lowered position. Staff explained that the poles are exposed when the bed rail is lowered.

A review of R1’s charting notes indicated that since 01/28/2025, R1 has experienced a total of five unwitnessed falls. No significant injuries were reported as a result of these falls. Following R1’s first three falls, charting notes dated 05/01/2025 indicated that Home Health recommended R1 receive assistance with all upright activities due to increased fall risk. Records further revealed that R1 experienced two additional unwitnessed falls on 06/05/2025 and 06/10/2025. Both incidents occurred in R1’s room. 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 supervision, resident fell resulting in a bruise” is deemed Unsubstantiated at this time.



It was reported that “Staff did not notify authorized representative of bruise on resident”, as It was alleged that R1’s responsible party was not notified in a timely manner of a bruise observed on R1. Interviews were conducted and records reviewed reflected that on 05/09/2025, Staff #1 (S1) observed a bruise on the right side of R1’s abdomen. According to charting notes, S1 informed R1’s private caregiver of the observed bruise. The private caregiver is listed in R1’s records as Emergency Contact #2. The charting notes further indicated that the private caregiver requested Tylenol for R1 and stated they would notify R1’s Power of Attorney (POA) of the bruise. LPA’s interview with S1 revealed, S1 stated that they asked R1’s private caregiver, who was present in R1’s room at the time, to send a text message to R1’s POA regarding the bruise.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20250515145455
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: 04/09/2026
NARRATIVE
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Continued from 9099-C

S1 further stated that after assessing R1, they also directly contacted R1’s POA to report the observed bruise. Interviews with R1’s POA and R1’s private caregiver revealed that both individuals stated they did not recall being notified of the bruise. Interviews were conducted with seven (7) facility staff. All seven staff stated that when a bruise or change in condition is observed, the med tech or appropriate staff are notified immediately, the resident is assessed, and notifications are made to the resident’s family or responsible party, the primary care physician, and any involved home health agencies. None of the staff interviewed reported concerns regarding untimely notification to required parties when a bruise or change in condition is observed. 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 did not notify authorized representative of bruise on resident” 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: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6