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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 12/06/2023
Date Signed: 12/06/2023 02:36:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 28-AS-20230210122615
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: 99DATE:
12/06/2023
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Imelda Villanueva - Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Questionable Death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to deliver the findings for the above-mentioned allegation. LPA met with Nirjara Acharyan and explained the reason for the visit.

On 01/27/23, a self-reported incident was received by the Woodland Hills Adult and Senior Care Regional Office. The incident was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator Dennis Douglas. A subsequent complaint regarding this incident with the allegation of questionable death was filed on 02/10/23, wherein Resident #1 (R1) was reported to have jumped off of the rooftop of the building of this facility resulting in a hospitalization and eventually, death of R1.

(continued to LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
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 5
Control Number 28-AS-20230210122615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/06/2023
NARRATIVE
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(continued from LIC 9099)

On 02/03/23 at around 9:13 AM, LPA conducted a case management to follow up on the above stated incident. LPA obtained copies of the facility records relevant to the investigation and interviewed staff and residents and conducted a thorough physical plant inspection.

During the course of the investigation, Investigator Doulglas interviewed the administrator and obtained records from Burbank Police Department (BPD), Hospital and County Medical Examiner. LPA’s interview with staff on 02/03/23 at around 12:30 PM revealed that only the maintenance staff has access to the third floor leading to the roof as it was off limits to residents and other staff and was always locked. Further interview revealed that staff were working on the roof to fix a leak but must have left the door unlocked giving R1 access. LPA’s interview with another two (2) staff also revealed that after the incident happened, police came, and these two (2) staff escorted the police to the rooftop and observed that the door leading to the rooftop was unlocked. The police were immediately able to enter and found the portable oxygen machine of R1 on the rooftop. Investigator Douglas review of the information obtained from BPD revealed that the incident was ruled out as suicide by jumping off the roof of the facility.

Based on the information gathered during the course of the investigation, the allegation is deemed substantiated at this time.

Citation issued, appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230210122615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2023
Section Cited
CCR
87468.1(a)(2)
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To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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Regional director agreed to ensure that the access to the rooftop will remain locked at all times by submitting a statement to this effect and put a big sign that only the staff are allowed to enter.
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Licensee did not ensure that the roof top was locked and inacessible to resident resulting to resident jumping off the rooftop of the building resulting to hospitalization and eventual death. This poses an immediate health, safety and personal rights risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 28-AS-20230210122615

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: 99DATE:
12/06/2023
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Imelda Villanueva - Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident was financially abused while in care

Staff failed to prevent resident from being harmed by another resident

Staff failed to provide a safe and comfortable environment for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with Executive Director Imelda Villanueva and explained the reason for the visit.

LPA conducted physical plant tour at 10:35 AM, requested facility documents relevant to the investigation at 11:00 AM, reviewed records between 11:00 AM to 12:30 PM and interviewed staff and resident between 12:30 PM to 1:45 PM. Regarding the allegation that Resident was financially abused while in care, it was alleged that the facility's director took money from R1's bank account. LPA's record review today at 11:00 AM revealed that R1 had preauthorized the facility to withdraw money from R1's bank account to pay for the rent. Further review also revealed that this has been the way R1 was paying own rent at the facility since R1's admission. LPA's interview with staff on 02/16/23 between 1:30 PM to 3:10 PM revealed that the facility changed their billing system sometime in January 2023 and missed withdrawing payment from R1's bank account for January 2023 rent. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230210122615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/06/2023
NARRATIVE
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(continued from LIC 9099-A)

Executive Director Nirjara Acharyan talked to R1 and obtained R1's approval for the withdrawal for January 2023's rent which R1 consented on 02/10/23. On 02/14/23 however, the staff received a notice from R1's bank that R1's account was closed and was not able to withdraw the rent money for January 2023. R1 subsequently agreed to a payment plan for R1 to pay an extra amount aside from R1's regular rent to cover for the missed January 2023 rent until fully paid.

Regarding the allegation that Staff failed to prevent a resident from being harmed by another resident, it was alleged that on an unknown date a resident beat up another resident. LPA's interview with the administrator today between 12:30 PM to 1:45 PM revealed that there was an aggressive resident used to live at the facility but was discharged since April of this year due to the resident's attitude and aggression toward other residents. Further review also revealed that the facility always reports any incident pertaining to this resident who was given several warning letters, eviction notices and eventually was sent to hospital for 51/50 hold and never got back to the facility.

Regarding the allegation that Staff failed to provide a safe and comfortable environment for residents, it was alleged that R1 was being harassed by two (2) staff and two (2) residents, R1 was urged by these two staff members and two residents to commit suicide. LPA's interview with staff today between 12:30 PM to 1:45 PM revealed that the two (2) staff mentioned by the reporting party (RP) denied any altercation or any misunderstanding with R1 and LPA's interview with Resident #3 (R3) who was mentioned by the RP revealed that R1 did not have depression nor any suicidal ideation during their conversation. Further, R3 denied harassing or mistreating R1 nor witnessed anyone, staff or resident in any way. LPA's record review and interview with staff also revealed the second resident mentioned by RP was non-existent as there was no one by that name used to live in the facility.

Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5