198603136-10-18-2021-28-AS-CYEE-C9D5AH-20211203184711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 10/18/2021
Date Signed: 10/18/2021 01:48:53 PM

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
10/12/2021 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211012134559

FACILITY NAME:	BURBANK RETIREMENT VILLA EAST		FACILITY NUMBER:	198603136
ADMINISTRATOR:	SOKOLOWSKI, MICHAEL		FACILITY TYPE:	740
ADDRESS:	1900 GRISMER AVE		TELEPHONE:	(818) 843-3141
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	100	CENSUS: 68	DATE:	10/18/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	S-1 and Facility Administrator (S-3)		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Resident does not attend scheduled appointments while in care.
Resident's grooming needs have not been met while in care.
Staff have not addressed a resident's change in medical condition while in care.
Staff does not provide a comfortable environment for a resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day investigation visit. LPA met with S-1 and discussed the purpose of today's visit. Facility Administrator (S-3) arrived at approximately 10 A.M..

During today's visit, LPA obtained the staff roster, resident roster, interviewed Staff #1 through Staff #4 (S-1 through S-4), interviewed Resident #1 through Resident #6 (R-1 through R-6) and obtained relevant documentation.

Refer to LIC 9099C for the contination of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211012134559

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: BURBANK RETIREMENT VILLA EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 10/18/2021

NARRATIVE

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Allegation: Resident does not attend scheduled appointments while in care. During this investigation, LPA interviewed Staff #1 through Staff #4 (S-1 through S-4) and interviewed Resident #1 through Resident #6 (R-1 through R-6). Interviewed staff indicated that residents are provided with transportation to scheduled appointments, going to the bank and/or going to the store. S-4 schedules the transportation for Residents. Interviewed staff indicated they have not received any complaints and/or concerns regarding transportation to attend scheduled appointments nor any issues in regards to Residents not being able to come in and out of the transportation vehicle. Interviewed Residents indicated they are aware that this facility provides transportation to medical appointments, stores and to the bank. Interviewed Residents indicated they schedule their transportation needs with the Receptionist (S-4). (5) out of the (6) interviewed residents indicated that they do not have any issues coming in and out of the transportation vehicle nor have any issues with being taken to their appointments. Staff and Resident interviews do not corroborate this allegation.

Allegation: Resident's grooming needs have not been met while in care. During this investigation, LPA interviewed Staff #1 through Staff #4 (S-1 through S-4) and interviewed Resident #1 through Resident #6 (R-1 through R-6). Interviewed staff indicated they have not received any complaints nor concerns in regards to staff not meeting Residents grooming needs (getting hair done). Interviewed staff indicated that some Residents go out on their own to the nearby beauty salon to get haircuts. (1) out of the (6) interviewed Residents indicated they have not groomed their hair for “approximately 3 weeks”. (5) out of the 6 interviewed Residents indicated they either go out on their own to get their haircut/hair done or have someone come to the facility to have their hair grooming needs met. Staff and Resident interviews do not corroborate this allegation.

Allegation: Staff have not addressed a resident's change in medical condition while in care. During this investigation, LPA interviewed Staff #1 through Staff #4 (S-1 through S-4) and interviewed Resident #1 through Resident #6 (R-1 through R-6). Interviewed staff indicated they have not received any complaints nor concerns in regards to staff not addressing residents change in medical condition while in care. Interviewed Staff indicated they assist Residents with scheduling appointments with their Physicians when there has been a change in medical condition. (1) out of the (6) interviewed Residents indicated they do not inform staff when they are feeling ill. (5) out of the (6) interviewed Residents indicated that they will notify Staff if they are not feeling well so that staff can assist with scheduling their medical appointments. Staff and Resident interviews do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211012134559

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: BURBANK RETIREMENT VILLA EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 10/18/2021

NARRATIVE

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Allegation: Staff does not provide a comfortable environment for a resident while in care. During this investigation, LPA interviewed Staff #1 through Staff #4 (S-1 through S-4) and interviewed Resident #1 through Resident #6 (R-1 through R-6). Interviewed staff indicated they have not received any complaints nor concerns in regards to staff not providing a comfortable environment for residents while in care. Interviewed staff indicated they have not received any complaints/concerns in regards to the facility being cold. (1) out of the (6) interviewed Residents indicated the facility is cold. (5) out of the (6) interviewed Residents indicated the facility provides a comfortable environment and have no concerns in . regards to the facility temperature. Staff and Resident interviews do not corroborate this allegation

Although the allegations may have happened or are 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, a copy of this report provided and appeal rights were provided to Facility Administrator (S-3).

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

LIC9099 (FAS) - (06/04)

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