198603136-3-16-2022-28-AS-WSHO-CCYRBF-20220329125241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 03/16/2022
Date Signed: 03/16/2022 11:58:15 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
12/15/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211215131442

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: 78	DATE:	03/16/2022
		UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Administrator, Nirjara Acharya		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff stole resident's money.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegation listed above. The initial complaint visit was conducted on 12/15/21. Licensee, Adam Zenou assisted with that visit.

The investigation consisted of the following: During the initial visit, Resident #1's (R1) file was reviewed. Interviews were conducted with the Licensee and Business Office Manager. R1 is no longer a resident of the facility and therefore was not interviewed at the time. On 1/19/22, LPA discovered R1's whereabouts and R1 was interviewed. Also on 1/19/22, LPA contacted an investigator from the Social Security office to inquire about R1's social security funds. During today's subsequent visit, 7 residents were interviewed.

The investigation revealed the following: It's alleged facility stole R1's social security money and stimulus checks. Facility was the payee for R1's social security funds. Facility records indicate R1 would receive money from facility staff when R1 requested it. R1's file contain signed withdrawal receipts signed by R1. Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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-20211215131442

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: 03/16/2022

NARRATIVE

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R1's money account statements indicate that the IRS deposited a $600 stimulus check to R1's account on 1/4/21. On 4/7/21, R1's account statement from the facility indicates a IRS check for $1,400 was rejected. The system rejected the check due to R1 being discharged from the facility on 4/1/21.

Social security investigator reviewed R1's social security account and did not find any suspicious activity. Staff interviewed deny the allegation that any money was stolen. Residents interviewed indicated they have not had any issues with staff and their finances.

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC9099 (FAS) - (06/04)

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