198603136-10-11-2022-28-AS-TVAO-CLPULF-20221201144038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:19:15 PM

Unsubstantiated

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
10/05/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20221005131717

FACILITY NAME:	BURBANK SENIOR VILLA EAST		FACILITY NUMBER:	198603136
ADMINISTRATOR:	ACHARYA, NIRJARA		FACILITY TYPE:	740
ADDRESS:	1900 GRISMER AVE		TELEPHONE:	(818) 843-3141
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	100	CENSUS: 93	DATE:	10/11/2022
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Marili Barajas - Administrator		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff did not address an open sore on resident's buttock in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Marili Barajas Business Manager and explained the reason for the visit.

The investigation consisted of the following: LPA requested staff/resident roster. LPA interviewed resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9) and staff #1(S1),#2(S2)#3(S3),#4(S4),#5(S5). LPA requested the following documents; physician's report, admission agreement, unusual incident report, face sheet, emergency and identification information, preplacement appraissal, and hospital discharge documents for resident #1(R1).

The investigation revealed the following: Regarding allegation: Staff did not address an open sore on resident's buttock in a timely manner. It is alleged that caregiver changing R1 noticed an open sore on right buttocks, notify the Technician about the sore, and nobody followed up with R1. Interviews with residents revealed 5 out of 9 residents interview stated to not require assistance to schedule appoitnments to the doctor and do not have (CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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-20221005131717

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: 10/11/2022

NARRATIVE

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any health needs that require assistance. 2 out of 9 residents interview stated facility staff assist with scheduling appointments or following up with needs.2 out of 9 residents interview stated facility does not assist them with scheduling medical appointments or health needs. Interviews with staff revealed 2 out of 5 staff interviewed stated R1's caregiver reported the open sore to the Med-Tech on 10/3/22 and R1 was send out to Kaiser Permanente Urgent Care on 10/3/22 and return to the facility with discharge documents on the same day. Documents review revealed R1 was seen at Kaiser Permanente on 10/3/22. Unusual incident report was submitted to the department on 10/3/22. Administrator stated that a follow up to obtain wound stage will be conducted and yearly in-service on identifying and care of wounds will be provided to staff.

Based on interviews, observation, and document review conducted, there was insufficient evidence to prove the allegation(s). 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 was conducted with Marili Barajas - Business Manager and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC9099 (FAS) - (06/04)

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