198603136-9-20-2021-28-AS-CYEE-C9D4L5-20211203181122

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 09/20/2021
Date Signed: 09/20/2021 12:47:15 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
09/14/2021 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210914102641

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: 69	DATE:	09/20/2021
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Facility Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not address a resident's hygiene needs while in care
Resident has not been properly fed while in care

INVESTIGATION FINDINGS:

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Liceising Program Analyst (LPA) Elizabeth Irra conducted an unannounced 10-day initial investigation for the above allegations. LPA met with Facility Administrator and discussed the purpose of today's visit.

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

Refer to LIC 9099C for the continuation 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: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

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-20210914102641

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: 09/20/2021

NARRATIVE

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Allegation: Staff did not address a resident's hygiene needs while in care During today’s visit, LPA interviewed Staff #1 (S-1) through Staff # (S-4) and interviewed Resident #1 (R-1) through Resident # 6 (R-6). Staff interviews revealed that Residents hygiene needs are being met while in care. Interviewed Staff indicated they perform Activities of Daily Living such as bathing/showering to Residents that require assistance. Interviewed staff indicated they have not received any complaints from anyone in regards to staff not meeting residents hygiene needs. Resident interviews revealed that staff meet their hygiene needs (including bathing and showering). (5) out of (6) interviewed Residents indicated their hygiene needs (with assistance from staff) are being met. (5) out of (6) interviewed Residents indicated they do not have any concerns with their hygiene needs not being met. (1) out of (6) interviewed Residents indicated they prefer to have (1) particular staff assist with hygiene needs (showers/bathing) and if that particular staff is not available, that Resident prefers to complete their own hygiene needs by using the sink to wash up. Staff and Resident interviews do not corroborate this allegation.

Allegation: Resident has not been properly fed while in care During today’s visit, LPA interviewed Staff #1 (S-1) through Staff # (S-4) and interviewed Resident #1 (R-1) through Resident # 6 (R-6). Staff interviews revealed that Residents are properly fed while in care. Interviewed staff indicated they have not received any complaints from anyone in regards to Residents not being properly fed. Resident interviews revealed that staff properly feed Residents. (5) out of (6) interviewed Residents indicated they are properly fed, are fed all meals and are happy with the food selection. (5) out of (6) interviewed Residents indicated they do not have any concerns with being properly fed. Interviews revealed that Residents receive their meals in their rooms (tray service) and are given the options to select alternatives such as sandwiches, soup and salads. 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.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

LIC9099 (FAS) - (06/04)

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