198603136-1-26-2023-28-AS-MVAO-CR8SX6-20230425141525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 01/26/2023
Date Signed: 01/26/2023 04:58:41 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
01/25/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 28-AS-20230125085608

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:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Nirjara Acharya, Administrator		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Facility staff does not ensure that resident receives food on a timely basis.
Facility staff does not ensure that resident's food does not have items missing.
Facility staff threw away resident's items.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 11:37 am to investigate the above allegations. LPA met with the administrator and disclosed the reason for the visit.
LPA conducted interviews with the administrator, seven (7) staff members and ten (10) out of ten (10) residents between 11:50am – 3:30pm. In addition, LPA reviewed facility records from 2:20pm to 3:15pm and obtained copies of pertinent documents relevant to the investigation.

LPA conducted a physical plant tour at approximately 12:30 pm 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.

Facility staff does not ensure that resident receive food on a timely basis.
During the physical plant tour, LPA observed residents in dining room and in their bedrooms eating

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: (818) 307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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-20230125085608

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: 01/26/2023

NARRATIVE

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(Cont from 9099)
lunch within the posted lunch hour. During interviews, residents revealed that they received food on a timely basis. One (1) out of ten (10) residents revealed that they receive food later because they request to have it later. Nine (09) out of ten (10) residents reveal they receive food on a timely basis. Interview with Administrator reveal that all staff work together to ensure sure that all residents receive their meals at the scheduled time or according to any arrangements made using a meal ticket.

Based on observations, interviews, and records reviewed there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Facility staff does not ensure that resident's food does not have items missing
LPA Smith interview with seven (7) out of (7) staff reveal that residents are given all items on the menu unless residents made prior arrangements to have alternate food items. Nine (9) out of ten (10) residents revealed that they receive all menu items, or they receive a requested food alternate when they submit a meal ticket. LPA observed R1 lunch meal received during time of interview. Meal observed to contain all items from the posted lunch meal including four (4) beverages, utensils, and napkins positioned on a serving tray.
Based on observations, interviews, and records reviewed there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Facility staff threw away resident's items.
LPA interview with nine (9) out of ten (10) residents revealed that staff will clean rooms and empty trash and may need to adjust items to clean around or under bed and furniture, but staff will not throw away their belongings. Interview with Administrator revealed that staff will not throw away any residents’ belongings. Administrator also revealed they have not received any complaints regarding any resident items being thrown away by facility staff.

Based on interviews there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: (818) 307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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