197609362-5-16-2024-31-AS-NMAN-D5RVV6-20240530164550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609362
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:07:03 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
02/16/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240216140950

FACILITY NAME:	IVY PARK AT BURBANK		FACILITY NUMBER:	197609362
ADMINISTRATOR:	DAWN SMITH		FACILITY TYPE:	740
ADDRESS:	2721 WILLOW STREET		TELEPHONE:	(818) 954-9500
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY:	130	CENSUS: 18	DATE:	05/16/2024
		UNANNOUNCED	TIME BEGAN:	10:14 AM
MET WITH:	Ethan Reid		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Memory care unit is in unsanitary condition.
Facility has shortage of cleaning supplies.
Facility has insufficient staffing to meet the needs residents.
Facility has roaches.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with Memory Care Director, Ethan Reid,
and explained the reason for the visit.

---Memory care unit is in unsanitary condition.

It was alleged that Resident #1 (R1) is in unsanitary condition, the odor in the room is very bad and has bowel movement in fingernails and carpet. To investigate the allegation, on 02/22/2024 LPA conducted a physical plant tour of memory care unit (Evergreen) at around 5:20 PM and interviewed four (04) staff between 6:00 PM to 07:00 PM. LPA was unable to interview residents. During the physical plant tour, LPA observed that all residents were clean and well groomed. LPA selected six (06) rooms at random, including R1’s room, and did not observe any stains on the carpet or experience any malodor.
(CONT on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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 3

Control Number 31-AS-20240216140950

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: 05/16/2024

NARRATIVE

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During interviews with staff, all staff stated the residents, and their rooms are always clean, and staff have never been witnessed residents with bowel movement under their fingernails. Staff stated the only time malodor is present is when residents has had a movement and when they are being changed. Staff added that residents are checked on every one (01) to two (02) hours or as needed.

Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

---Facility has shortage of cleaning supplies.

It was alleged that staff bring cleaning supplies from home because manager told them that heavy duty cleaning supplies are not within the facility budget. To investigate the allegation, on 02/22/2024 LPA conducted a physical plant tour of memory care unit (Evergreen) at around 5:20 PM and interviewed four (04) staff between 6:00 PM to 07:00 PM. During the physical plant tour, LPA observed an overabundance of cleaning supplies. The cleaning supplies are refilled by a third-party agency as part of a subscription. During interviews with staff, all staff stated that they have never purchased cleaning supplies with their own money and that the facility has plenty of cleaning supplies available. Staff #1 added that a former staff once purchased a preferred cleaning supply but was immediately refunded and asked not to do it again.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

---Facility has insufficient staffing to meet the needs residents.

It was alleged that residents require extensive care and supervision and are left in bed. To investigate the allegation, on 02/22/2024 LPA requested documents at around 5:15 PM, conducted physical plant tour of memory care unit (Evergreen) at around 5:20 PM and interviewed four (04) staff between 6:00 PM to 07:00 PM. LPA was unable to interview residents. A review of the staff roster and schedule shows that there are three (03) caregivers and one (01) MedTech during each shift. During interviews with staff, all staff confirmed that there are three (03) caregivers and (01) MedTech during each shift.
(CONT. on LIC 9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20240216140950

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: 05/16/2024

NARRATIVE

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Staff added they are each assigned up to six (06) residents and that of the six (06), one (01) to two (02) residents are scheduled for showering and that between four (04) to five (05) residents require assistance with activities of daily living such as bathing, toileting and dressing which can take up to thirty (30) minutes per resident.

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

---Facility has roaches.

It was alleged that there are roaches and bugs in the facility caused by leftover food in the cabinets and counter tops. To investigate the allegation, on 02/22/2024 LPA conducted physical plant tour of memory care unit, Evergreen, at around 5:20 PM and interviewed four (04) staff between 6:00 PM to 07:00 PM. LPA was unable to interview residents. During the physical plant tour, LPA checked every counter top, drawer, cabinet, under the refrigerator, and cabinets and did not observe any leftover foods, roaches or signs of roach excrement. During interviews with staff, all staff stated they do not leave food on the counter tops and have never witnessed roaches in the facility.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

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

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

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