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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609362
Report Date: 08/05/2025
Date Signed: 08/05/2025 02:30:49 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
05/16/2025 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20250516163441
FACILITY NAME:IVY PARK AT BURBANKFACILITY NUMBER:
197609362
ADMINISTRATOR:BRITTNEY BUCHANNANFACILITY TYPE:
740
ADDRESS:2721 WILLOW STREETTELEPHONE:
(818) 954-9500
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:130CENSUS: 94DATE:
08/05/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Laura Kephart - Operations SpecialistTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not prevent a resident from sustaining multiple falls while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent visit to this facility to further investigate the above allegation. LPA met with Operations Specialist Laura Kephart and explained the reason for the visit.

LPA conducted a physical plant tour at around 10:00 AM, requested copies of facility documents relevant to the investigation at 10:38 AM, reviewed records between 10:45 AM to 11:45 AM and interviewed staff and residents between 11:45 AM to 1:45 PM. Regarding the allegation that Staff did not prevent a resident from sustaining multiple falls while in care, it was alleged that Resident #1 (R1) had two (2) falls within two (2) months, LPA's record review today revealed that R1 was hospitalized on 03/03/25 and 04/15/25 due to fall. LPA's interview with R1 today at 1:05 PM revealed that R1 was with a caregiver on both times R1 fell and on both occasions, the care staff tried to break R1's fall. LPA's interview with Staff #1 (S1) who was present during the initial incident on 03/03/25 revealed that S1 was called through the personal call button (pendant). (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
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-20250516163441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT BURBANK
FACILITY NUMBER: 197609362
VISIT DATE: 08/05/2025
NARRATIVE
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(continued from LIC 9099)

At around 5:00 PM and proceeded to assist R1 transfer to the toilet from the bed through the wheelchair, upon returning to the wheelchair from the toilet, R1's leg locked and unable to bend, a medical condition of R1 which happens from time to time. This made R1 panic so S1 sat R1 on the floor. On 04/15/25 incident, LPA's interview with Staff #3 (S3) revealed that S3 did not remember S1 falling but LPA's interview with R1's private caregiver revealed that S1 fell on 04/13/25 with S3 protecting R1.

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
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.ASC, 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
05/16/2025 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20250516163441

FACILITY NAME:IVY PARK AT BURBANKFACILITY NUMBER:
197609362
ADMINISTRATOR:BRITTNEY BUCHANNANFACILITY TYPE:
740
ADDRESS:2721 WILLOW STREETTELEPHONE:
(818) 954-9500
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:130CENSUS: 94DATE:
08/05/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Laura Kephart - Operations SpecialistTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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2
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9
Staff did not reassess a resident in care.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent visit to this facility to further investigate the above allegation. LPA met with Operations Specialist Laura Kephart and explained the reason for the visit.

LPA conducted a physical plant tour at around 10:00 AM, requested copies of facility documents relevant to the investigation at 10:38 AM, reviewed records between 10:45 AM to 11:45 AM and interviewed staff and residents between 11:45 AM to 1:45 PM. Regarding the allegation that Staff did not reassess a resident in care, LPA's record review on 05/21/25 revealed that Resident #1 (R1) was hospitalized on 03/03/25 and 04/15/25 due to a fall but did not have a new assessment on record to address R1's fall and the last Assessment on record was on 01/28/25. LPA's interview with the former Executive Director on 05/21/25 confirmed that due to a change in staffing, assessment was not done yet on R1 but will be scheduled soon with R1's family member. (continued on LIC 9099-A-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
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-20250516163441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT BURBANK
FACILITY NUMBER: 197609362
VISIT DATE: 08/05/2025
NARRATIVE
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(continued from LIC 9099-A-C)

Based on the information gathered during this and prior visit, the allegation is deemed substantiated at this time.

Citation issued. Appeal rights discussed and given.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20250516163441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2025
Section Cited
CCR
87463(f)
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The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation, if any, of the appropriate licensed medical professional, and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident’s record.
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Cleared during visit. An assessment was done on 05/27/25 after CCL's initial visit on 05/21/25.
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This requirement is not met as evidenced by:

Based on records review and interview, there was no assessment made to R1 after 2 hospitalizations, this poses a potential health and safety risk to the 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: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5