198603136-3-13-2023-28-AS-RORN-CPWQZ9-20230314123623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 02/24/2023
Date Signed: 03/13/2023 10:43:17 AM

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
12/12/2022 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221212130852

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: 92	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Mariii Barajas, Manager		TIME COMPLETED:	03:46 PM

ALLEGATION(S):

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Staff did not safeguard resident personal belongings
Staff threatened resident

INVESTIGATION FINDINGS:

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**** This amended report supersedes report dated 02/24/2023. It was created to remove identifiling information from origianal 9099 and 9099C report and add additional response from staff. The additional revision did not change any other aspects of the report and all aspects including the findings remain the same.***
LPAs Alberto Lopez and Erik Zaragoza made subsequent unannounced visit to investigate the above allegations. LPAs met with Office Manager Marili Barajas and explained the purpose of the visit.
The investigation consisted of interviews with staff #1-#6 (S1-S6) and residents #1-#9 (R1-R9). LPAs reviewed and obtained staff and residents’ rosters, R10 Physicians report dated 10/20/2021 and preplacement appraisal. R10 inventory of personal effects dated 9/25/2020. R10 refused to fill out but signed the form. Residents’ departure inventory list dated 11/23/2022.

(Continued on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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-20221212130852

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: 02/24/2023

NARRATIVE

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Regarding allegation: Staff did not safeguard resident personal belongings. It is alleged that when R10 asked for R10 belongings after leaving the facility, Facility did not return some personal items including an electric scooter (wheelchair).

LPAs interviewed office manager (S1) at facility and S1 stated that all of R10 belongings were given to R10 with the exception of the electric scooter because R10 had given it to roommate R1. S2 stated that R10 gave her Electric Wheelchair to R1. R10 called facility on 11/23/2022 and told S6 that R10 had given the Electric Wheelchair to R1 because she didn't want it. Roommate (R1) of R10 stated that R10 never used the electric wheel chair and gave it to R1 before R10 left. R10 refused to complete inventory list when admitted to facility so it is not documented what R10 brought in with to facility. Discharge inventory list had all R10 personal items listed with exception of electric wheel chair. List was not signed due to missing electric wheelchair. R1 stated R1 had no need for electric Wheelchair and asked staff to remove it from R1 room because it was taking too much space. R1 did not know what happen to wheelchair after that. 6 of 6 staff denied the allegations and stated they take care of all the residents personal belongings and valuables W1 stated W1 packed all of R10 belongings. The laundry staff (S3) stated that residents place all clothing they want washed in a black bag and S3 makes sure that it is all returned to the appropriate resident. 7/9 residents stated they have never lost any personal belongings. Therefore, there was insufficient evidence to corroborate with the allegation.

Regarding allegation: Staff threatened resident. LPA interviewed staff and residents and 6 of 6 staff interviewed stated they have never threatened a resident or witness a staff threaten a resident. 9/9 residents interviewed could not collaborate the allegations and several residents stated that residents have never been threaten or witness any staff threatening a resident. Some residents stated that staff is very nice.

Based on statements and interviews conducted with staff, residents, review of resident file and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 held, and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC9099 (FAS) - (06/04)

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