<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609362
Report Date: 02/19/2025
Date Signed: 02/21/2025 01:48:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
09/20/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240920163810
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: 88DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Brittney Buchannan- Executive DirectorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is understaff.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2.19.2025 Licensing Program Manager (LPM) Eva Miller, Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda, Marianna Agban, Nadia Shahbazian, and Angela Panushkina arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPAs was greeted by Briittany Buchanan and was advised the reason for the visit.

Entrance interview conducted.

On 9/25/2024 at 11AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care.

Allegation #1: Facility is understaffed.

Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
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 5
Control Number 31-AS-20240920163810
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT BURBANK
FACILITY NUMBER: 197609362
VISIT DATE: 02/19/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation that facility is understaffed. It was alleged that the facility is understaffed, wherein facility staff are not able to attend to the residents needs in a timely manner. LPA did a record review at 10 AM and requested copies of records at 12:00 PM for R1’s physician report, appraisal needs and services, pre-placement appraisal, CSMDR, and other necessary documents. On 9.25.24 LPA interviewed twenty (20) residents out of seventy (70) and eight (8) staff between 11:08 AM to 2:30 PM. Interviews revealed residents were not being checked regularly due to being short staffed. Staff interviewed made statements to the effect that they need assistance and are short staffed.

Based on the information gathered, during the course of the investigation, 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 to Executive Director (ED).
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
09/20/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240920163810

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: 88DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Brittney Buchannan- Executive DirectorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility do not meet resident's hygiene needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2.19.2025 Licensing Program Manager (LPM) Eva Miller, Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda, Marianna Agban, Nadia Shahbazian, and Angela Panushkina arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPAs was greeted by Daisy Hernandez and was advised the reason for the visit.

Entrance interview conducted.

On 9/25/2024 at 11AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care.

Allegation #1: Facility do not meet resident's hygiene needs.

Conitnue to LIC 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20240920163810
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT BURBANK
FACILITY NUMBER: 197609362
VISIT DATE: 02/19/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation that that facility did not meet resident hygiene needs. It was alleged that staff do not properly shower residents. Record review of staff training records revealed all staff had been trained on resident hygiene and bathing. Shower schedule was also given to LPA and records show that all the residents were getting their scheduled shower. On 9.25.2024 LPA interviewed twenty (20) residents out of seventy (70) and eight (8) staff between 11:08 AM to 2:30 PM. Interviews with residents revealed they receive enough assistance with showering from facility staff and an outside agency. Interviews with staff and the executive director revealed the facility revealed no shower issues were raised by residents, family, or visitors. Residents receive shower assistance twice (2x) to thrice (3x) a week. Based on record review and interviews, the facility meets residents’ showering needs.

Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

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

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20240920163810
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/19/2025
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
Facility personnel, shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not `met as evidenced by: Based on LPA’s observations, review of facility files and information provided
1
2
3
4
5
6
7
Administrator will provide sufficient staff to meet resident needs as per CCR 87411(a) and will give LPA copies of staff schedules documenting sufficient personnel to meet the resident needs and copies of required documentation of staff training for existing personnel and any
8
9
10
11
12
13
14
during interviews it was determined that the facility did not provide a sufficient number of staff to meet the needs of residents in care including but not limited to incontinent care, resulting in the risk to the health and safety of residents in care.
8
9
10
11
12
13
14
 newly hired for the purpose of correcting this deficiency..
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5