198603136-6-24-2023-31-AS-AALR-CT4U7W-20230624152036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603136
Report Date: 06/24/2023
Date Signed: 06/24/2023 03:21:08 PM

Document Has Been Signed on 06/24/2023 03:21 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

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: 99	DATE:	06/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Nirjara Acharya, Regional director		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPAs) Antonia Alvizar and Gary Tan conducted an unannounced Required One (1) year at this facility today. LPAs met with Executive Director, Imeda Villanueva, Regional Director, Nirjara Acharya and explained the reason for the visit. A tour of the physical plant was conducted at 10:30AM and the following was noted: The facility consist of a two story structure that contains the following: Entrance / Lobby 1, an office for staff, and Lobby 2 / TV room areas for residents’ use, an interior courtyard, a dining room, a kitchen, a laundry room on first and second floors, storage space on first and second floors. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located in the lobby. Sign in sheet, hand sanitizer, gloves and masks are available. Some staff were observed to be wearing mask during this visit. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. Laundry room on the first and second floors and was observed to be locked. Laundry detergents, cleaning agents and other toxins are stored space in the second floor locked storage inaccessible to the residents. Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BURBANK SENIOR VILLA EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 06/24/2023

NARRATIVE

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The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lit.

The bathroom was checked for cleanliness and proper operation. LPA observed that there are appropriate grab bars in the showers and toilets. The hot water temperature measure was at a range of 111.2°F to 113.3°F. There were enough clean linen available in the closets.

Medications were kept in a locked medication carts in the medication room. The medications were observed to be locked and inaccessible to residents. There are multiple complete first aid kits located in the medication room.

Facility emergency disaster plan was reviewed. Facility disaster drill was last conducted on 03/03/2023. A fire inspection by the LAFD was last performed on 06/15/2023. In addition to the physical plant inspection, residents and staff records were reviewed.

There is no body of water at the facility. Back and front yard passageways were observed to be clear from obstruction. There is a shaded area in front of the building for residents.

LPAs reviewed files of five (5) randomly selected residents. Residents’ files appear to be complete and updated. Six (6) files were also reviewed, staff files appear to be complete and updated.

No Health and safety issues observed.
Exit interview conducted. A copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2023

LIC809 (FAS) - (06/04)

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