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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609362
Report Date: 10/14/2022
Date Signed: 10/14/2022 03:01:44 PM


Document Has Been Signed on 10/14/2022 03:01 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:HEIGHTS AT BURBANK, THEFACILITY NUMBER:
197609362
ADMINISTRATOR:DAWN SMITHFACILITY TYPE:
740
ADDRESS:2721 WILLOW STREETTELEPHONE:
(818) 954-9500
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:130CENSUS: 85DATE:
10/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Dawn SmithTIME COMPLETED:
03:09 PM
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CM made unannounced visit to follow up on incident report dated 10/02/2022 regarding un-witnessed fall of resident that resulted in hip fracture. According to executive Director Dawn Smith, Resident pulled call cord and Med Tech Hadrian Torres made his way to resident's room and found her on the floor in the bathroom. Resident stated R1 hit her head and 911 call was made. Paramedics assessed her and stated she was fine Initially resident stated R1 was feeling fine and refused trip to hospital. On 10/02/2022 LVN ReIna Rubi informed resident daughter that R1 was complaining of pain and daughter pick up resident and took R1 to St Joseph Hospital where she was admitted due to left hip fracture. Resident is currently at Glendale rehabilitation center doing fine.

Tour of facility with Executive director was completed and no health and safety issues were observed.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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