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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609135
Report Date: 03/08/2022
Date Signed: 03/09/2022 01:33:14 PM


Document Has Been Signed on 03/09/2022 01:33 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:BURBANK HILLS COMFORT LIVINGFACILITY NUMBER:
197609135
ADMINISTRATOR:HANNESYAN, NARINEFACILITY TYPE:
740
ADDRESS:2745 N MYERS STTELEPHONE:
(818) 736-5097
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:6CENSUS: 5DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Narine Hanenesyan TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jewel Baptiste conducted an annual inspection visit at the facility with focus on the infection control domain, food, and medication review. LPA Baptiste met with Narine Hannesyan administrator and explained the reason for the visit. Upon arrival LPA observed administrator and staff#3 with out mask or face covering. Staff#3 is observed not associated and living at the facility.

Facility is licensed to serve 6 over the age of 60 years old, which 6 non- ambulatory, of which 1 maybe bedridden. Facility has a hospice wavier for 3. At the time of inspection facility census is 5. Facility is located in a residential neighborhood, single story house, living room/ dining room, kitchen, 4 bedroom, 1 staff bedroom, and 2 bathrooms one of which is located in bedroom #2.

LPA conducted file review of administrator and staff #1. During the review LPA observed administrator certificate expired 3/31/2021 and CPR card expired 9/2020. Staff #1 was missing employee rights. LPA conducted file and medication review for resident #1, #2 and #3. Resident #1 file was missing pre-appraisal, needs and service and functionality form. Resident #2 physician report was blank, pre-appraisal and needs and service, and capability and functional form was missing. Resident #3 did not have physicians’ orders for medications. Resident #3 file was missing, pre-appraisal, needs and service, and capability and functional form was missing.

continued on 809c

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 21


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135
VISIT DATE: 03/08/2022
NARRATIVE
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LPA and administer conducted tour of the facility together and observed the following: Kitchen area has sufficient food worth 2 days of perishables and 7 days of non-perishables. All bed rooms has sufficient lighting, furniture, and all the required bedding Bathrooms were observed with skid mats built into shower and grab bars. Water temperature was tested between 106.4- 106.5 degrees F, which is within the required 105-120 degrees F. LPA observed COVID-19 signs posted through out the facility, bathrooms observed with soap, signs and paper towels. Screening conducted for residents, staff and visitors. LPA observed PPE supplies for at least 30 days. Per administrator N95 fit testing was conducted for all staff. LPA observed fire extingusher is fully charged and dual units with carbon monixide detectors built in, they were tested and in working order.

There were deficiencies found during today’s inspection. Deficiencies are cited from California Code of regulations, Title 22 and/or H&S Code 1569() and citations are listed on the attached LIC809D. If the deficiencies are not corrected by the noted due date, civil penalties may be assessed.




Exit interview conducted, appeal rights provided, and copy of report left at the facility.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 14 of 21
Document Has Been Signed on 03/09/2022 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(b)(10)
Resident Records
(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Type A
Section Cited
CCR
87465(a)(7)
Incidental Medical and Dental Care Services
(7) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 15 of 21


Document Has Been Signed on 03/09/2022 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents physcians report was blank and not update, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2022
Plan of Correction
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Administrator will make sure all residents physcians report and medical assistment is updated and placed in there files. A copy of each report will be sent to licensing.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 16 of 21


Document Has Been Signed on 03/09/2022 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(f)(1)
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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3
4
Section Cited
Deficient Practice Statement
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2
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4
POC Due Date:
Plan of Correction
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2
3
4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 17 of 21