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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609362
Report Date: 11/21/2024
Date Signed: 11/21/2024 02:13:39 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/26/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20240226110712
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: 72DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Brittney BuchannanTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Facility retained resident with prohibited health condition.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Abeye Duguma, Angelica Segovia and Nadia Shahbazian conducted an unannounced subsequent complaint visit to the facility. LPA met with Executive Director, Brittney Buchannan, and explained the reason for the visit.

---Facility retained resident with prohibited health condition.

It was alleged that facility retained a resident with mrsa and did not prevent mrsa outbreak. To investigate the allegation, on 03/06/2024 LPA Antonia Alvizar- Ettima requested pertinent documents at around 12:25p.m. and interviewed four (04) staff from around 12:40p.m. to 1:35p.m. A review of the Pristine Home Health Physician's Orders, MS Diagnostic Laboratories LLC, and Resident Care Notes revealed that resident tested positive for mrsa on 02/23/2024 and was transferred to Glendale Care Center on 02/27/2024.

(CONT. on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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 2
Control Number 31-AS-20240226110712
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT BURBANK
FACILITY NUMBER: 197609362
VISIT DATE: 11/21/2024
NARRATIVE
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During interviews with staff, all staff stated once facility received the positive results for Resident #1 (R1) on 02/25/2024, they isolated R1, immediately contacted R1's physician and, per physician's orders, R1 was transferred to Glendale Care Center on 02/27/2024.

Based on interviews and record review, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2