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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609362
Report Date: 12/22/2022
Date Signed: 12/22/2022 01:27:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2020 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200616133724
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: 87DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Milca Osorio (Director of Assisted Living)TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility did not have sufficient staff to meet residents' needs.
Facility retained a resident requiring a higher level of care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Milca Osorio (Director of Assisted Living) and explained the purpose of the visit.

During the initial complaint investigation conducted on 06/24/20, LPA conducted a health and safety check. LPA toured the facility via Facetime with Dawn Smith (Administrator) and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Wash basins, showers/bathtubs and toilets are operable. There are no immediate health and safety concerns during the initial investigation.

During today's investigation, LPA obtained a copy of the Staff/Resident roster, interviewed Staff #7 to #11 in the private dining room and interviewed Residents #4 to #12 in the private dining room.
Continue to LIC9099C....
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
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 5
Control Number 31-AS-20200616133724
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HEIGHTS AT BURBANK, THE
FACILITY NUMBER: 197609362
VISIT DATE: 12/22/2022
NARRATIVE
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In regard to the allegation: Facility did not have sufficient staff to meet residents' needs. The department reviewed Home Health records, Hospice records, Hospital records, interviewed Resident #1's (R1) primary physician, family member, Staff #1 to #6 and Resident #2 (R2) and #3 (R#). R1's home health nurse and primary doctor concur that R1 needed a one-on-one private care provider to monitor R1 while R1 was alone in R1's room. The facility was providing the highest level of care (maximum assist) for R1; however, the care provided was insufficient to meet resident needs and prevent R1 from falling. R1 was falling while alone in R1's private room and did not fall when being assisted by facility staff. Although the R1's family member were encouraged to obtain a private one on one care giver to assist, family member failed to do so and the R1 continued to fall while residing in the facility. The facility notified R1’s hospice agency of R1’s falls on 10/02/19, 10/03/19 & 10/04/19. After being notified of R1s falls, the hospice agency checked on R1s condition and found no injuries. Although the facility was not contractually required to provide a one-on-one care to R1, the facility failed to meet residents needs by not providing assistance to R1, who had prior falls that the facility was aware of. The information and evidence obtained during the investigation, sufficiently supports the allegation, thus this allegation is substantiated.

In regard to the allegation: Facility retained a resident requiring a higher level of care. The department reviewed Home Health records, Hospice records, Hospital records, interviewed Resident #1's (R1) primary physician, Family member, Staff #1 to Staff #6 and Resident #2 and Resident #3. R1's home health nurse and primary doctor concur that R1 needed a private care provider to monitor R1 on a one-to-one basis, while R1 was alone in R1's room. The facility was providing the highest level of care (maximum assist) for R1, yet the staff assistance was insufficient to prevent R1 from further falls, which occurred on 10/02/19, 10/03/19 & 10/04/19. R1 sustained falls while alone in R1's private room but did not sustain falls when being assisted by facility Staff. Although the R1's family member were encouraged by the facility to obtain a private one on one caregiver to assist R1, the family members failed to do so and R1 continued to fall in the facility. The facility was not contractually required to provide R1 with a one-on-one care and supervision, however, the facility failed to assist R1 in obtaining a higher level of care than the facility could provide to prevent further falls. The information and evidence obtained sufficiently supports the allegation, thus this allegation is substantiated.

Based on the department's interviews and record review, the investigation revealed: The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted and a copy of this report and appeal rights provided to Milca Osorio.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20200616133724
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HEIGHTS AT BURBANK, THE
FACILITY NUMBER: 197609362
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidence by: The facility failed to meet residents needs by not providing
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Licensee shall provide a signed statement to the department that they have read and will comply with this section by the POC date.
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assistance to R1, who had prior falls that the facility was aware of.
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Type A
12/23/2022
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet
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Licensee shall provide a signed statement that they have read and will comply with this section and provide additional training to care giving staff and provide proof to the department by the POC date.
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their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: The facility failed to assist R1 in obtaining a higher level of care than the facility could provide to prevent further falls.
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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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2020 and conducted by Evaluator Kruz Long
COMPLAINT CONTROL NUMBER: 31-AS-20200616133724

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: 87DATE:
12/22/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Milca Osorio (Director of Assisted Living)TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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2
3
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Resident was chemically restrained.
Resident sustained multiple falls at the facility, including fracture.
Facility failed to seek resident timely medical attention.
Facility mismanaged and falsified resident's records.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Milca Osorio (Director of Assisted Living) and explained the purpose of the visit.

During the initial complaint investigation conducted on 06/24/20, LPA conducted a health and safety check. LPA toured the facility via Facetime with Dawn Smith (Administrator) and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Wash basins, showers/bathtubs and toilets are operable. There are no immediate health and safety concerns during the initial investigation.

During today's investigation, LPA obtained a copy of the Staff/Resident roster, interviewed Staff #7 to #11 in the private dining room and interviewed Residents #4 to #12 in the private dining room.
Continue to LIC9099C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20200616133724
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HEIGHTS AT BURBANK, THE
FACILITY NUMBER: 197609362
VISIT DATE: 12/22/2022
NARRATIVE
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In regards to the allegation: Resident was chemically restrained. Interviews with Staff who assists with medication assistance indicate they have never chemically restrained a Resident nor have they witnessed other Staff chemically restrained a Resident and medication assistance is conducted based on doctor's orders. Interviews with 9 of 9 Residents indicate that they have never been chemically restrained. The information obtained did not sufficiently support the allegation, thus the allegation is unsubstantiated.

In regards to the allegation: Resident sustained multiple falls at the facility, including fracture. Interviews were conducted with facility residents, facility employees, and R#1's doctor. None of the persons interviewed observed any neglect or lack of supervision by the facility Staff. Staff denied neglect or lack of supervision. R#1's doctor visited R#1 in the facility and never witnessed any neglect or lack of supervision and R#1 never complained regarding care received at the facility. R#1 was receiving maximum assist by the facility Staff and did not have any falls while in their care. R#1's falls occurred while R#1 was alone in the private room. R#1's hospital records, home health, and hospice records were obtained and reviewed indicating no abuse or neglect concerns were noted in the records. The hospital records indicated R#1 sustained a right femur fracture which was treated for and released to a Skill Nursing Facility. Home health records indicated a home health nurse spoke with the family member and suggested family member to obtain private one on one care to prevent further falls. The family member did not obtain additional help for R#1 as suggested. The information obtained did not sufficiently support the allegation, thus the allegation is unsubstantiated.

In regards to the allegation: Facility failed to seek resident timely medical attention. R#1 fell several times the week prior to R#1 being admitted to the hospital but did not report any pain. R#1 had a fall on 10/7/2019 and reported pain to the right leg after the fall. Hospice records indicated the facility notified hospice of the fall and a hospice nurse saw R#1 at the facility after the fall and did an assessment and R#1's pain decreased after receiving Tylenol. The following day R#1 was again found on the floor of R#1's room and reported being in pain. A mobile x- ray was requested, and the results showed R#1 sustained a femur fracture. R#1 was transported to the hospital and was treated for injury. The facility notified hospice, the family member as well as R#1's primary doctor of the falls. The information did not sufficiently support the allegation, thus this allegation is unsubstantiated.

In regards to the allegation: Facility mismanaged and falsified resident's records. Interviews with 5 of 5 Staff indicate they have never mismanaged and falsify resident records nor have they witnessed other Staff mismanage and falsify resident records. A review of R#1's records does not indicate any mismanagement or falsification. The information did not sufficiently support the allegation, thus this allegation is unsubstantiated.

Based on the department's interviews and record review, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted with Milca Osorio and a copy of this report provided.

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5