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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603136
Report Date: 02/03/2023
Date Signed: 02/03/2023 02:59:15 PM


Document Has Been Signed on 02/03/2023 02:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA



FACILITY NAME:BURBANK SENIOR VILLA EASTFACILITY NUMBER:
198603136
ADMINISTRATOR:ACHARYA, NIRJARAFACILITY TYPE:
740
ADDRESS:1900 GRISMER AVETELEPHONE:
(818) 843-3141
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 97DATE:
02/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Nirjara Acharya - AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this facility regarding the self reported incident occurred on 01/27/22 wherein Resident #1 (R1) was reported to be seen by the staff on the floor of the parking lot area bleeding. LPA met with administrator Nirjara Acharya and explained the reason for the visit.

LPA conducted physical plant tour at around 10:00 as the parking area was occupied by the ambulance and fire truck upon LPA's arrival. LPA also requested copies of facility documents relevant to the investigation at 10:45 AM and interviewed staff and resident between 11:00 AM to 1:30 PM.

LPA's interview with the administrator today at 11:00 AM revealed that 911 was called immediately and R1 was brought to the hospital where R1 passed and local police also came to investigate the incident. LPA's interview with Resident #2 (R2) today at 12:10 PM also revealed that R2 who is living on the second floor (the building is a two storey building only) saw R1 fell from above which could only mean that R1 fell from the roof top. LPA's observed that the door leading to the rooftop is locked and inaccessible to resident during today's visit.

There is no health and safety issues noted during this visit.

Further investigation is required at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Alex EstradaTELEPHONE: (818) 596-4364
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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