198603136-5-20-2022-28-AS-SCOL-CF8PQN-20220609113124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 05/20/2022
Date Signed: 05/20/2022 03:16:05 PM

Substantiated

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
05/12/2022 and conducted by Evaluator Alberto Lopez

COMPLAINT CONTROL NUMBER: 28-AS-20220512163229

FACILITY NAME:	BURBANK SENIOR 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: 97	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Marili Barajas, Manager		TIME COMPLETED:	03:22 PM

ALLEGATION(S):

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Resident was stuck in facility elevator
Facility elevator is not operating appropriately

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lopez conducted a complaint visit to investigate the allegation listed above. LPA met with Manager Marili Barajas and explained the reason for the visit.

The investigation consisted of the following: Interviewed resident #1-9 (R1), Manager and five facility staff (S#1-S#5 were interviewed. LPA obtained resident and staff roster, SIR dated 5/08/22, 7 elevator repair invoices dated 09/17/21, 10/13/21, 12/03/21, 12/07/21, 03/02/22, 05/08/22, and 5/12/22, no elevator repair logs are kept by facilty and fax transmittal for 05/08/22 SIR

Allegation: Resident was stuck in facility elevator
Manager and 4/5 staff and 7/9 residents collaborated allegation that resident was stuck in elevator on 5/08/22 LPA tested elevator and it moved up and down properly, However, phone was not functioning and it was not known how long it has been in disrepair. Based on information and documentation received allegation is SUBSTANTIATED
(continued on 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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 4

Control Number 28-AS-20220512163229

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 SENIOR VILLA EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 05/20/2022

NARRATIVE

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Allegation: Facility elevator is not operating appropriately

Manager and LPA tested elevator and it functioned properly going up and down with no issues, however, phone inside elevator is not functioning and it is not known how long it has been in disrepair Based on information and documentation received allegation is SUBSTANTIATED

Exit interview was conducted and copy of report provided to Manager Marili Barajas

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
05/12/2022 and conducted by Evaluator Alberto Lopez

COMPLAINT CONTROL NUMBER: 28-AS-20220512163229

FACILITY NAME:	BURBANK SENIOR 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: 97	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Marili Barajas, Manager		TIME COMPLETED:	03:22 PM

ALLEGATION(S):

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Staff did not report unusual incident to CCL

INVESTIGATION FINDINGS:

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Allegation: Staff did not report unusual incident to CCL

Facility manager provided copy of SIR dated 05/08/22 and fax trasmitted proving that incident was reported as required. Based on information and documentation received allegation is UNSUBSTANTIATED

Exit interview was conducted with Manager and copy of repost provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20220512163229

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 SENIOR VILLA EAST	FACILITY NUMBER: 198603136
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/27/2022 Section Cited CCR 87691(a)	1 2 3 4 5 6 7	Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by	1 2 3 4 5 6 7	Administrator will ensure the elevator phone is in good repair and submit proof of invoice showing the repair was made. The POC must be submitted to CCL by the due date 05/27/22
	8 9 10 11 12 13 14	On 05/20/22, at 9:33am upon LPA arriving at the facility, LPA tested the elevator by pressing the elevator button and observed the elevator to be in fuctioning and going up down, however the phone inside the elevator was not working and it is not known how long it has been in disrepair. R1 was trapped inside and phone did not function preventing R1 from calling for help	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

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