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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609362
Report Date: 10/05/2024
Date Signed: 10/05/2024 02:42:01 PM

Document Has Been Signed on 10/05/2024 02:42 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
Lookup Error,
, CA
FACILITY NAME:IVY PARK AT BURBANKFACILITY NUMBER:
197609362
ADMINISTRATOR/
DIRECTOR:		DAWN SMITHFACILITY TYPE:
740
ADDRESS:2721 WILLOW STREETTELEPHONE:
(818) 954-9500
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 130CENSUS: 76DATE:
10/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Beatriz Martinez/Health Services Director TIME VISIT/
INSPECTION COMPLETED:
02:41 PM
NARRATIVE
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On 10/5/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Beatriz Martinez/Health Services Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (130) elderly adults ages 60 and above, of which (100) can be non-ambulatory and (30) Bedridden. The facility has an approved hospice waiver for (12).

The facility is an 8-story high rise consisting of the following: the administrative offices, main dining room, main laundry room, medication room, staff room, commercial kitchen, activity room, common bathrooms and lobby are located on the first floor. The second floor is fire cleared for the Memory Care Unit which is equipped with a delayed egress system. Floor #3 through floor #8 houses the rooms for the assisted living residents.

LPA Iniguez and the Health Services Director toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (7) bedrooms and (7) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 115.5°F to 117.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: IVY PARK AT BURBANK
FACILITY NUMBER: 197609362
VISIT DATE: 10/05/2024
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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 3/25/24.

A review of (6) residents' service files and (6) staff personnel files was maintained in order. LPA reviewed (6) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-See D pages for more details.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to / Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2024
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Document Has Been Signed on 10/05/2024 02:42 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 10/05/2024 at 02:11 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
,
, CA

FACILITY NAME: IVY PARK AT BURBANK
FACILITY NUMBER: 197609362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)
87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. 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 evidenced by:
Deficient Practice Statement
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Based on, the licensee did not comply with the section cited above in during annual inspection LPA tested signal system from a resident's bathroom, staff took 30 minutes to clear alarm which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee will ensure facility has suffiecient staff at all times. As plan of correction, administrator will re-train care staff about the importance of tending in a timely maner the alarms from residents rooms. A proof of training will be sent to LPA via email before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2024 02:42 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 10/05/2024 at 02:18 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
,
, CA

FACILITY NAME: IVY PARK AT BURBANK
FACILITY NUMBER: 197609362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(15)
General Food Service Requirements
(b) The following food service requirements shall apply: (15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above in kitchen staff/service staff not wearing hairnets while inside kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee will ensure all persons engage in food preparation and service shall observe personal hygene and food services sanitation at all times. As plan of correction, administrator will re-train kitchen and serving staff about the importance of wearing a hairnet while serving food and preparing it. Proof of training will be sent to LPA via email before POC due date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having a recent annual evaluation for a resident with dementia/alzheimer's as primary diagnosis which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee will ensure all residents that has dementia/alzheimer's as primary diagnosis, their annual evaluations are current. As plan of correction, administrator will acquire recent physicians report and file it on resident's file. Proof of recent medical report will be sent to LPA via email before POC due date.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2024


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