197609490-6-10-2023-31-AS-AINZ-CSNP85-20230610110457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609490
Report Date: 06/10/2023
Date Signed: 06/10/2023 11:05:06 AM

Document Has Been Signed on 06/10/2023 11:05 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME:	BURBANK VILLA INC		FACILITY NUMBER:	197609490
ADMINISTRATOR:	SARKISYAN, SEROP		FACILITY TYPE:	740
ADDRESS:	2324 REESE PL		TELEPHONE:	(323) 610-0000
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	6	CENSUS: 6	DATE:	06/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Johnny Sarkisyan-Administartor		TIME COMPLETED:	11:04 AM

NARRATIVE

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On 6/10/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Johnny Sarkisyan/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) non-ambulatory elderly adults ages 60 and above and approved hospice waiver for (3). The facility is approved for dementia. There are six (6) level 4 developmentally disabled clients over the age of 60. The facility is serviced by Lanterman Regional Center.

The facility is a single-story home located in a residential neighborhood that is licensed for 6 non-ambulatory clients. A hospice waiver for 3 residents is in place. It consists of 6 bedrooms, 2 bathrooms, living room/dining area, kitchen with laundry area, outdoor covered patio, and detached garage. The last fire drill was conducted on 5/3/2023.

LPA Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (3) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. Cleaning solution found unlocked in bathroom#1 LPA inspected rooms: #1, #2, and #3 and smoke and carbon monoxide combo are all operable conditions. The water temperature ranged from 102.5F° – 114.2F°. The room temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) -98-1755
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: BURBANK VILLA INC	FACILITY NUMBER: 197609490
	VISIT DATE: 06/10/2023

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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. Working landline phones are available on-site. A review of (3) residents' service files (R1-R3) and (3) staff personnel files (S1-S3) and Medication Administration Records (MAR) were maintained in order. First AID kit was checked.

LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview conducted with Johnny Sarkisyan/Administrator and a copy of the appeal rights were given at the time of the visit.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) -98-1755
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/10/2023 11:05 AM - 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
Lookup Error,
, CA

FACILITY NAME: BURBANK VILLA INC	FACILITY NUMBER: 197609490
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in leaving cleaning supplies unlocked under the bathroom sink which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2023
	Plan of Correction
1 2 3 4	CLEARED-Licensee removed all cleaning supplies during LPAs visit. Licensee will ensure all cleaning supplies will be locked, a re-training for all staff need to be done before POC due date and sent the copy of training attendance to LPA by email or text.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Eva M Alvarez	TELEPHONE: (323) -98-1755
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

LIC809 (FAS) - (06/04)

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