197609362-2-19-2025-31-AS-EMIR-DH9TRY-20250602145817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609362
Report Date: 02/19/2025
Date Signed: 02/19/2025 01:43:57 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
12/06/2024 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20241206133513

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: 88	DATE:	02/19/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Brittney Buchannan, Executive Director		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff does not provide adequate supervision resulting in resident engaging in physical altercations with other residents.
Staff did not seek medical attention to resident.
Staff does not provide a safe environment to residents.
Staff do not notify responsible parties of incidents.

INVESTIGATION FINDINGS:

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At 9:30am, Licensing Program Analysts (LPAs) Angela Panushkina, Nadia Shahbaziana, Mariana Agban, Leslie Ngo-Castaneda and Licensing Program Manager (LPM) Eva Miller conducted an unannounced subsequent complaint visit at this facility to deliver final findings. The team met with the Executive Director and explained the reason for the visit.

An initial visit was conducted by LPA Panushkina on 12/12/2024 and interviews and record reviews were made. Moreover, at 10:05am, LPA requested resident and staff roster. At 10:20am, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Appraisal Needs and Services Plan, Reporting Requirements, etc., relevant to the investigation. At approximately 10:25am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:30am – 01:30pm, LPA conducted an interview with the Executive Director, Health Services Director, Resident Care Coordinator, four (4) staff, and ten (10) residents.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
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 3

Control Number 31-AS-20241206133513

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: 02/19/2025

NARRATIVE

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Lastly, LPA obtained copy of a Police Report on 12/31/2024.

Allegation: Staff does not provide adequate supervision resulting in resident engaging in physical altercations with other residents.

It was alleged that Resident #1 (R1) was struck by Resident #2 (R2) in the dining room. To investigate this allegation, LPA conducted an interview with the Executive Director (ED) and was informed that ED was not aware of the incident until Health Services Director (HSD) received a phone call from R1's family member. Interview with the HSD revealed that on 12/05/24, HSD was scheduled to work and did not witness R2 strike R1. Interview with HSD revealed that R1 did not inform any staff members about the incident nor did R1 complain about any head injury to the facility staff. Interview with four (4) staff members corroborated the statement provided by the HSD, and all four (4) staff informed LPA that they have not witnessed R2 engaging in physical altercations with R1. During the interview with the witness (R3), LPA was informed that he/she was sitting by R1 and observed R2 approached their table but did not witness R2 engaging in physical altercation. Additionally, LPA conducted interviews with ten (10) residents and nine (9) out of ten (10) residents interviewed denied the above allegation. Lastly, a review of the Police Report revealed that an investigating officer inspected R1's head and did not observe any redness, swelling or injuries. Therefore, based on interviews, documentation received and record reviews this allegation is deemed Unsubstantiated at this time.

Allegation: Staff did not seek medical attention to resident.

It was alleged that R2 struck R1 and no medical attention was provided by the facility staff. To investigate this allegation, LPA conducted an interview with R1 and was informed that he/she was sitting in a dining room and around 1:00pm, R2 approached R1 from the back and hit R1 in the head with an unknown object. LPA was also informed that R1 did not inform any of the staff members, instead R1 went to R1's room and took a nap. Sometime around 4:00pm, R1 contacted the family member to inform about the incident. During the interview with HSD, LPA was informed that once the staff is aware of any incidents, it's immediately brought to her attention and if medical attention is required staff will follow the policy,

Continue on LIC9099-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
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 3

Control Number 31-AS-20241206133513

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: 02/19/2025

NARRATIVE

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so that immediate assistance can be provided and an Incident Report can be completed within two (2) hours. LPA was also informed that since R1 did not inform anyone and no staff witnessed any incidents, no one was aware of any medical attention being required for R1. Interview with nine (9) out of ten (10) residents confirmed that the facility staff always provide medical attention as required. Therefore, based on interviews, record reviews and information gathered, this allegation is deemed Unsubstantiated at this time.

Allegation: Staff does not provide a safe environment to residents.

To investigated this allegation, LPA conducted an interview with the Executive Director (ED), Resident Care Coordinator (RCC) and Health Services Director (HSD) and was informed that prior to employment, all staff are provided with initial training on basic services and care and supervision to be able to provide a safe environment to residents. LPA conducted an interview with four (4) staff members who indicated they made sure that all residents are safe and comfortable. In addition, interview with nine (9) out of ten (10) residents expressed no concerns regarding this allegation. Residents revealed that they are happy with the facility and staff. Therefore, based on interviews and record reviews, this allegation is deemed Unsubstantiated at this time.

Allegation: Staff do not notify responsible parties of incidents.

It was alleged that R1's responsible party was not informed of an incident that occurred on 12/05/24. To investigate this allegation, LPA conducted an interview with the Executive Director (ED), Resident Care Coordinator (RCC) and Health Services Director (HSD) and was informed that once there is an incident, the staff immediately notifies the upper management who then contact the family/responsible party/conservator. Interviews with ED, RCC and HSD revealed that the facility staff was not aware of the incident with R1, thus there was no reason for them to contact the responsible party. Based on interviews, and information gathered, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
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)

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