198603136-1-18-2023-28-AS-MVAO-CPCSRY-20230224130706

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 01/18/2023
Date Signed: 01/18/2023 06:17:02 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 28-AS-20230113145359

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: 98	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Marili Barajas, Office Manager.		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident sustained a fall while in care
Staff did not provide adequate care and supervision to a resident

INVESTIGATION FINDINGS:

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At approximately, 10:00am Licensing Program Analyst (LPA), Angela Panushkina arrived to this facility in response to the above mentioned allegation. LPA met with the Administrator and explained the reason for the visit.

LPA conducted a physical plant walk through, at approximately 10:30am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit.

LPA conducted an interview with the Office Manager, MedTech, two (2) staff members, ten (10) out of eleven (11) residents between 10:30am - 12:50pm. In addition, LPA reviewed facility records from 1:00pm to 2:00pm and obtained copies of pertinent documents relevant to the investigation.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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-20230113145359

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: BURBANK SENIOR VILLA EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 01/18/2023

NARRATIVE

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Allegation: Resident sustained a fall while in care

To investigate this allegation LPA, Panushkina, interviewed with the Office Manager and was informed that the resident or resident's roommate usually reports an incident to MedTech. Once reported, the MedTech examines the resident and calls 911. Then, the MedTech reports everything to the Administrator and a written report is being submitted to the Community Care Licensing Division (CCLD).

During today's walk though and interviews, around 11:30am, LPA along with the Office Manager found out from Resident #1 (R1) that they had a fall last night and did not report to anyone. The Office Manager, immediately, requested a transportation and R1 was taken to Emergency Room (ER). Interview with R1 also revealed that they didn't think it was important to report since this was their first fall. In addition, R1's roommate also confirmed that R1 didn't have any falls in the past. Before LPA completed this investigation, LIC624 (Unusual Incident/Injury Report) was completed and submitted to CCLD by the Office Manager. Based on the information gathered during today's visit, the allegation is deemed Unsubstantiated at this time.

Allegation: Staff did not provide adequate care and supervision to a resident

During today's visit LPA interviewed R1 and R1's roommate and was informed that no fall incident had occurred on 01/11/2023. In addition, interview with the Office Manager revealed that they were not aware of R1's fall incident and that no one reported anything for 01/11/2023. Lastly, LPA was informed that all reported falls are being assessed/examined by MedTech and an interview with the MedTech confirmed that R1 did not report any fall incidents on 01/11/2023. Based on the information gathered during today's visit, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

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