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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609362
Report Date: 10/16/2025
Date Signed: 10/16/2025 04:42:51 PM

Document Has Been Signed on 10/16/2025 04:42 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:IVY PARK AT BURBANKFACILITY NUMBER:
197609362
ADMINISTRATOR/
DIRECTOR:		ANGELA SMITHFACILITY TYPE:
740
ADDRESS:2721 WILLOW STREETTELEPHONE:
(818) 954-9500
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 130CENSUS: 81DATE:
10/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Angela Smith-Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst Nadia Shahbazian arrived at the facility at 10:00AM today to conduct a One (1) year Required visit. LPA met with Angela Smith-Executive Director/Administrator and explained the purpose of this visit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools during today's visit. A tour of the physical plant was conducted between 12:30AM through 2:45PM with Executive Director and LPA observed the following:

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). Current census is (81) with (4) residents on hospice care.

The facility is an eight story building consisting of the following: the administrative offices, main dining room, living room, main laundry room, medication room, staff room, commercial kitchen, activity room, common bathrooms, 2 patios and lobby, located on the first floor. The second floor is fire cleared for the Memory Care Unit which is equipped with a delayed egress system. Floors 3 through 8 house assisted living residents.

Required postings were observed in the lobby and throughout the facility. The facility's smoke/mono-oxide detectors are hard wired, facility is equipped with fire sprinkler system. Fire drill was last conducted on October 03, 2025. There are fire extinguishers throughout the facility hallways on all floors; all extinguishers were last serviced on July 14, 2025.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: IVY PARK AT BURBANK
FACILITY NUMBER: 197609362
VISIT DATE: 10/16/2025
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Bedrooms: LPA visited ten (10) random rooms from each floor. All bedrooms were observed to be appropriately furnished with required beds, chairs, chest drawers and lighting with linens and comforters on all beds. All bedrooms observed to be clean and clear from obstruction. In two (2) bedrooms LPA pulled the signal pull cord and in each occasion, staff came for assistance within 4-6 minutes.

Bathroom: There are common bathrooms on multiple levels. LPA visited ten (10) bathrooms located in the bedrooms. LPA observed foldable shower chair, non-skid mats and grab bars in the showers and near the toilets. The water temperature measured in range of 106.9 to 113.5 degrees Fahrenheit. All resident bathrooms and common area bathrooms were observed to be clean and sanitary.

Kitchen: Facility’s kitchen door was observed to be locked and inaccessible to residents. Facility has a walk-in refrigerator, freezer, commercial oven, ice maker, ice-cream freezer and dishwasher. LPAs observed an adequate supply of perishable foods for two (2) days, and non-perishable food supply for seven (7) days stored in the walk-in refrigerator and walk-in freezer. Food was properly labeled and stored. Emergency food is kept in a separate locked area, in a parking storage. Knives and sharp utensils are stored in the kitchen; inaccessible to residents. Detergents and chemicals are locked in a storage room outside of the kitchen.

Laundry Room: Facility has a commercial laundry room for kitchen use, located on the first floor. There are laundry rooms in fifth and sixth floors, designated for washing resident clothes.

Common areas: These areas include a gym, theater, hair salon on the 8-th floor. There is a library on the sixth floor, an internet lounge on the fourth floor, a doctor's lounge on the seventh floor. There is a piano lounge/living room on the first floor and activity rooms on various floors. LPA observed two (2) outdoor patio areas, one located outside the lobby, the second behind the Private Dining Room by the kitchen and a bistro near the kitchen for daily snacks. All common areas were appropriately furnished with tables and chairs and adequate lighting and all areas were observed to be neat and clean. The facility has a fire sprinkler system, internet, cable and wi-fi access. Facility does not have a pool but has water fountains located in the patio.

Due to time constraints LPA was unable to complete today's annual visit and will return on a later date to complete the annual report. Exit interview conducted, and a copy of report issued.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC809 (FAS) - (06/04)
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