Ivy Park at Burbank.

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 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 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.

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Case Management Visit to confirm the admission of Resident #1 (R1). Upon arrival at 10:00am, LPA met with Fabiola Moreno - Memory Care Director and explained the purpose of the visit. . LPA obtained copies of the LIC 500 and the Resident Roster. Admission of R1 to the facility was confirmed, date of admission was on 03/12/2025. LIC 809 signed and copy provided. Exit interview conducted.

The investigation revealed that on 09/13/2024, Staff #1 (S1) was observed kissing R1 on the lips by R2. S1 initially denied the allegation during the facility's internal investigation but later acknowledged kissing R1 on the forehead during questioning by the Burbank Police Department detective. Throughout the investigation, interviews with facility staff indicated that S1 exhibited unusual behaviors with residents, such as caressing their hands and feet. Ultimately, S1 was arrested by the Burbank Police Department and terminated on 09/23/24. It was determined that S1 sexually assaulted R1; therefore, based on the conducted interviews and the review of the investigation reports, the allegation is deemed substantiated. An immediate civil penalty of $500 will be assessed today for sexual assault. The Executive Director was informed that additional civil penalties may be applied based on Health and Safety Code 1548. Deficiency cited (refer to LIC9099-D). Exit interview conducted. Appeal rights were provided, and a copy of this report was issued to the Executive Director.

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 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 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.

During interviews with staff, all staff stated once facility received the positive results for Resident #1 (R1) on 02/25/2024, they isolated R1, immediately contacted R1's physician and, per physician's orders, R1 was transferred to Glendale Care Center on 02/27/2024. Based on interviews and record review, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview was conducted and a copy of report was issued.

To test staff response time, LPA triggered delayed egress alarms multiple times and observed an average response time of fifteen (15) seconds. LPA also observed three (03) caregivers and one (01) MedTech providing care to seventeen (17) memory care residents. During interviews with staff, all staff stated they respond to the delayed egress alarm within five (05) to fifteen (15) seconds. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility staff do not respond to the residents calls for assistance in a timely manner. It was alleged that help calls taking twenty (20) to thirty (30) minutes to get to residents’ rooms. To investigate the allegation, LPA conducted a physical plant tour at around 11:00a.m. and interviewed four (04) staff. During the physical plant tour, LPA selected six (06) rooms at random, used the call button system and observed an average response time of five (05) minutes. LPA also observed three (03) caregivers and one (01) MedTech providing care to seventeen (17) memory care residents. During interviews with staff, all staff stated they respond to the resident call buttons within three (03) to six (06) minutes. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility staff are not qualified. It was alleged that there is a lack of a qualified manager to handle the safety of confused elderly. To investigate the allegation, LPA requested records at around 12:00p.m. A review of staff files revealed that the manager at the time the complaint was filed had all required training, including Elopement Response Plan, CPR, First Aid and Service Excellence with Residents and Families training. Based on record review, 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.

Allegation: Staff is not able to meet resident's needs due to inadequate staffing. In regards to the allegation it is alleged that over the past 30 to 40 days there is not enough staffing at the facility to assist residents. Interview with the Executive Director revealed caregiver assistance is dependent on the level of care a resident may need or requires. Caregivers are provided assignment sheets with residents names to provide assistance to. Assistance with activities of daily living is dependent on what level of care the resident was assessed for. Caregivers are still required to respond to call button alerts from residents not on assignment sheet. Review of two (2) assignment sheets for the assisted living unit provided revealed 31-36 names with residents requiring varying degrees of assistance with toileting, transfer, bathing, dressing, grooming , escorting or status checks. For the assisted living unit there are three (3) shifts with three (3) to four (4) caregivers and one (1) to two (2) med-techs per shift with exception to the overnight shift. Interviews with staff and residents revealed on Wednesday, July 17, 2024 at 6 a.m. the Wellness Nurse at the time received a call from a med-tech informing her the only two (2) caregivers on site for the assisted living unit of the facility were threatening to walk out if they did not have a third caregiver on site. Both caregivers, Staff #1 (S1) and staff #2 (S2) confirmed in interviews they had been working with only two staff on most days for about two weeks and had gone from four caregivers to three caregivers prior to the two weeks. Interview with Health Services Director corroborates on the day at 6 a.m. staff threatened to walk out and were not performing their usual duties if a third caregiver did not arrive. Staff walked out at approximately 6:45 a.m. - 7 a.m. without having provided care to residents in the assisted living unit. Health Services Director, states the Wellness Nurse at the time called a caregiver from the Memory Care unit to cover until more staff arrived. LPA was able to confirm with memory care staff they received a call from the Wellness Director at 6:55 a.m. to assist. Three other staff arrived and were able to provide assistance to residents some time around 7:30 a.m. Interviews with five (5) out of the eight (8) residents interviewed revealed they have waited over 30 mins to receive assistance with four (4) of those residents citing the specific incident that occurred on Wednesday as one of the days they waited over 30 minutes. One (1) out of the eight (8) residents indicated that they have only heard from other residents concerns about response time. Seven (7) out of eight (8) residents interviewed are satisfied with the care being provided only citing the wait time to receive the assistance as a concern. Interviews indicate Wednesday was an Isolated incident, however, interviews indicate staffing has been a concern prior to the incident. Therefore 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 Executive Director via email.

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) 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 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.

Licensing Program Analyst (LPAs) Antonia Alvizar and Gary Tan arrived at the facility at 9:00 AM today to conduct a One (1) year Required visit. LPAs initially met with Activity Director, Krista Cheshire, later joined Administrator, Dawn Smith and explained the purpose of this visit. The facility has an approved mitigation and infection control plan on file. LPA Alvizar and LPA Tan utilized the Compliance and Regulatory Enforcement (CARE) tools, and a tour of the physical plant was conducted at 11:00 AM with Krista Cheshire and Keith Bernabe during today visit and observed the following: The facility has a fire clearance for one hundred (100) non ambulatory of which, 30 maybe bedridden. Hospice waiver for twelve (12) residents. Delayed egress is approved for Dementia Unit on second floor. Required postings were observed in the entry area. The facility's smoke alarms are hard wired as back up and tests are done on a monthly basis. Fire drill was last conducted on September 03, 2023. There are fire extinguishers throughout the facility hallways on all eight (8) floors, all extinguishers were last serviced on January 05, 2023. The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette, and physical distancing) posted. The PPE supplies is located at the Executive Director office and Medication Room upon entry there is hand sanitizers by the elevator and sign in sheet at the time of visit. The facility maintains a temperature of 75 degrees Fahrenheit. All eight (8) floors have a mini activity room located at the end of each floor. Continued on LIC809C 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 Bedrooms: At 11:30 AM LPAs were able to observe ten (10) random rooms from each floor. All bedrooms observed to be appropriately furnished with sufficient lighting. LPAs observed appropriate bed linen and comforters on all beds. All bedrooms observed to be clean and clear from obstruction. Bathroom: At 11:30AM LPAs observed ten (10) bathrooms located in the bedrooms. LPAs observed appropriate grab bars located in the shower and around the toilet. The water temperature measured in range of 113.7 between 118.0 degrees Fahrenheit. Non-skid mats were located in the shower. Bathrooms are stocked and equipped with soap and paper towels. Hand towels are not shared. Laundry Room: At 11:10 AM LPAs observed the laundry rooms located on the and first floor for commercial laundry, fifth and sixth floors for resident clothing residents have access to the laundry area to do their own laundry, clean and clear from obstruction and storing laundry supplies. Medications: LPA observed two (2) medication carts at 11:15 AM stored in the medication room on the first floor to be locked and storing medication and inaccessible to residents. The refrigerator was observed to be doubled locked storing narcotic medications. The facility has first aid kits located in the medication room. Theater room, living/game room on each floor, and common areas: At 11:45 AM LPAs observed these areas to be appropriately furnished with tables and chairs and adequate lighting. Observed to be neat and clean. The facility has a gym on the eighth (8) floor currently being used by a resident at the time of inspection. The theater room is located on the 8th floor and was unoccupied at the time of inspection. LPAs observed two (2) outdoor patio areas, one located outside the lobby, the second behind the Private Dining Room, and the surrounding grounds of the facility which were clean and clear from debris and obstruction. These areas are equipped with owing and tables with chairs for seating and additional tables and chairs for lounging. LPAs observed a Fire Department Fire Protection Equipment Performance Report dated 03/24/2023 to have passed, the fire alarm system are hard wired and interconnected throughout facility and tested internally every month. The facility has a fire sprinkler system. No body of water was observed or located on the premises. No deficiencies cited, exit interview conducted, and a copy of report issued.