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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609362
Report Date: 07/23/2024
Date Signed: 07/23/2024 05:26:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2024 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20240719164328
FACILITY NAME:IVY PARK AT BURBANKFACILITY NUMBER:
197609362
ADMINISTRATOR:DAWN SMITHFACILITY TYPE:
740
ADDRESS:2721 WILLOW STREETTELEPHONE:
(818) 954-9500
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:130CENSUS: 75DATE:
07/23/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Beatriz Martinez (Health Services Director)TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff is not able to meet resident's needs due to inadequate staffing.
INVESTIGATION FINDINGS:
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On 07/23/24, at 10:00 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced, initial complaint visit. At approximately 10:10 a.m. LPA met with the Executive Director, Britney Buchannan, the Health Services Director, Beatriz Martinez, the Memory Care Director, Ethan Reid and the Business Director, Leigh Ikeda. LPA explained the purpose of the visit. An entrance interview was conducted. LPA was provided copies of the resident roster, staff schedule and staff assignments.

At approximately 10:30 a.m. while waiting to conduct a physical plant tour LPA interviewed two (2) residents. At approximately 10:40 a.m. LPA along with the Health Services Director and the Memory Care Director, conducted a physical plant tour to ensure the health and safety of the residents in care. From 10:51 a.m. to 2:06 p.m., LPA interviewed eight (8) out of (9) residents with one (1) resident refusing to be interviewed and eight (8) staff, four (4) of which provide direct care to residents as caregivers. From 2:45 p.m., LPA reviewed four (4) resident files. LPA reviewed and obtained copies of residents' physician's reports, appraisals, service plans and assessments. (Continue to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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 3
Control Number 31-AS-20240719164328
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT BURBANK
FACILITY NUMBER: 197609362
VISIT DATE: 07/23/2024
NARRATIVE
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Allegation: Staff is not able to meet resident's needs due to inadequate staffing. In regards to the allegation it is alleged that over the past 30 to 40 days there is not enough staffing at the facility to assist residents. Interview with the Executive Director revealed caregiver assistance is dependent on the level of care a resident may need or requires. Caregivers are provided assignment sheets with residents names to provide assistance to. Assistance with activities of daily living is dependent on what level of care the resident was assessed for. Caregivers are still required to respond to call button alerts from residents not on assignment sheet. Review of two (2) assignment sheets for the assisted living unit provided revealed 31-36 names with residents requiring varying degrees of assistance with toileting, transfer, bathing, dressing, grooming , escorting or status checks. For the assisted living unit there are three (3) shifts with three (3) to four (4) caregivers and one (1) to two (2) med-techs per shift with exception to the overnight shift. Interviews with staff and residents revealed on Wednesday, July 17, 2024 at 6 a.m. the Wellness Nurse at the time received a call from a med-tech informing her the only two (2) caregivers on site for the assisted living unit of the facility were threatening to walk out if they did not have a third caregiver on site. Both caregivers, Staff #1 (S1) and staff #2 (S2) confirmed in interviews they had been working with only two staff on most days for about two weeks and had gone from four caregivers to three caregivers prior to the two weeks. Interview with Health Services Director corroborates on the day at 6 a.m. staff threatened to walk out and were not performing their usual duties if a third caregiver did not arrive. Staff walked out at approximately 6:45 a.m. - 7 a.m. without having provided care to residents in the assisted living unit. Health Services Director, states the Wellness Nurse at the time called a caregiver from the Memory Care unit to cover until more staff arrived. LPA was able to confirm with memory care staff they received a call from the Wellness Director at 6:55 a.m. to assist. Three other staff arrived and were able to provide assistance to residents some time around 7:30 a.m. Interviews with five (5) out of the eight (8) residents interviewed revealed they have waited over 30 mins to receive assistance with four (4) of those residents citing the specific incident that occurred on Wednesday as one of the days they waited over 30 minutes. One (1) out of the eight (8) residents indicated that they have only heard from other residents concerns about response time. Seven (7) out of eight (8) residents interviewed are satisfied with the care being provided only citing the wait time to receive the assistance as a concern. Interviews indicate Wednesday was an Isolated incident, however, interviews indicate staffing has been a concern prior to the incident. Therefore the allegation is deemed Substantiated at this time.

Exit Interview conducted. Deficiencies cited (refer to LIC 9099-D). Appeal Rights explained and provided. Copy of report provided Executive Director via email.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20240719164328
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT BURBANK
FACILITY NUMBER: 197609362
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
07/25/2024
Section Cited
CCR
87411(a)
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(a)Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports....This requirement is not met as evidence by:
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Executive Director (ED) stated a job fair is being held July 31st. Facility has hired two caregivers. ED also states staff involved on Wednesday were given final write ups. Facility provided copies of in-service held on various topic including but not limited to individualize service plans and status checks. POC cleared today.
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Based on interviews conducted, residents and staff revealed, residents have waited an unreasonable amount of time to receive assistance citing the number of staff on shift to provide care, which posed an immediate health, safety and personal rights 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: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3