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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 12/13/2021
Date Signed: 12/13/2021 10:52:20 AM



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
12/03/2021 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211203111612
FACILITY NAME:BURBANK RETIREMENT VILLA EASTFACILITY NUMBER:
198603136
ADMINISTRATOR:SOKOLOWSKI, MICHAELFACILITY TYPE:
740
ADDRESS:1900 GRISMER AVETELEPHONE:
(818) 843-3141
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 69DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Licensee, Adam ZenouTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Staff did not provide a refund to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegation listed above. LPA met with Licensee, Adam Zenou and explained the reason for the visit.

The investigation consisted of the following: Resident #1 (R1) and two facility staff were interviewed. R1's file was reviewed including R1's admission agreement.

The investigation revealed the following: It's alleged R1 was not provided a refund after moving out of the facility on 10/17/21. Allegedly R1 was verbally told he/she would receive a refund since R1 paid the rent for October 2021. R1 was interviewed and indicated that he/she did not provide the facility with a 30-day notice, but insisted that Staff #1 (S1) verbally promised a pro-rated refund from 10/18/21 - 10/31/21. S1 was interviewed and indicated he/she did not promise a refund. R1's admission agreement dated 5/1/20 states residents are required to provide a 30 day advance notice of intent to move.
Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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 2
Control Number 28-AS-20211203111612
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: 12/13/2021
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview held. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2