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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 11/18/2022
Date Signed: 03/06/2023 12:22:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/17/2022 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221117125637
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:
11/18/2022
UNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Marili Barajas, Office Manger TIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not provide adequate care and supervision to a resident while in care.
Facility staff made inappropriate comments to resident while in care.
Facility staff did not treat resident with dignity and respect.
Facility staff did not ensure that an Ombudsman poster is displayed at the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**** This amended report supersedes report dated 11/18/2022. It was created to add additional resident information and new staff responses to questions to support the first 3 allegation findings and to correct resident # from R1 to R2 on allgation #1 The additional revision did not change any other aspects of the report and all aspects including the findings remain the same.***

Licensing Program Analyst(s) (LPA) Alberto Lopez conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Administrator NIrjara Acyarya and explained the reason for the visit. On Subsequent visit on 03/06/2023 LPA met with Office Manager Marili Barajas and expalined pupose of visit.

The investigation consisted of the following: LPA requested the following documents: physician's report, for #1(R1) and #2(R2) and personnel and staff rosters. LPA interviewed resident #1(R1), #2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9) Administrator and staff #1(S1),#2(S2)#3(S3),#4(S4),#5(S5).





(CONTINUED ON 9009C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
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 2
Control Number 28-AS-20221117125637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BURBANK SENIOR VILLA EAST
FACILITY NUMBER: 198603136
VISIT DATE: 11/18/2022
NARRATIVE
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The investigation revealed the following:
Regarding allegation: Facility staff did not provide adequate care and supervision to a resident while in
care. It is alleged that residents are not assisted while in care. Administrator and 7/7 staff all stated they provide best care to all residents. 6/9 residents did not collaborate the allegations. Administrator and 7/7 staff denied the allegations. LPA pulled call cord and staff arrived promptly. R2 asked and was taken to hospital due to health issues she was experiencing during the visit. R1 states that she advocates for R2 and that staff do not like it and talk behind her back. R1 stated that when staff come to room and if resident is on floor, staff just leave her there for about 5 minutes. S4 stated that they do leave resident on the floor for a while as precaution until it is determined safe to pick resident up. S6 stated that every fall in facility is recorded on incident report and sent to CCLD.
S7 stated that protocol for falls at the facility requires Med-Tech to check resident for injuries and assess if it is safe to assist resident off the floor. Staff 7 stated that as far as she knows, R2 did not have any recorded falls and no record of falls could be found for R2. R3 stated R3 does not need care and supervision. R5 stated care is provided to R5. R6 stated that facility provides care and supervision and not aware of any problems. R8 stated that R8 has no problems with care at facility. R9 stated that good care is provided.

Regarding allegation: Facility staff made inappropriate comments to resident while in care. It Is alleged that staff berate R1 and talk behind her back. Administrator and 7/7 staff denied the allegations. 7/9 residents could not collaborate the allegations. R2 stated that staff is very nice to R2. R3 Stated staff do not talk inappropriately to R3. R4 stated R4 has never witnessed that. R5 stated staff are not inappropriate. R6 stated staff are very kind. R8 has never heard of staff making inappropriate comments to residents. R9 stated that staff never make inappropriate comments.

Regarding allegation: Facility staff did not treat resident with dignity and respect. It is alleged that staff yell and point fingers at R1 when addressing R1. Administrator and 7/7 staff denied the allegations and 7/9 residents could not collaborate the allegations. R2 stated that staff treat R2 with dignity and respect. R4 Stated R4 has not experienced this. R5 stated R5 is treated with dignity and respect. R6 stated that staff are very respectful. R7 stated that allegation is not true.

Regarding allegation: Facility staff did not ensure that an Ombudsman poster is displayed at the facility. It is alleged that ombudsman poster was taken down at facility. Administrator and 5/5 staff stated that poster has always been at facility. 8/9 residents could not collaborate the allegations. 1/9 residents stated number was wrong. LPA observed the poster when walking into the facility on the left wall and tested the phone number and number was correct.

Although the allegations 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 allegations are Unsubstantiated.


Exit interview conducted with Office Manager Marili Barjas. A copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2