198603136-8-2-2023-28-AS-RORN-CUHUXL-20230808155830

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 08/02/2023
Date Signed: 08/02/2023 03:13:13 PM

Substantiated

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
11/19/2021 and conducted by Evaluator Joe Katrdzhyan

COMPLAINT CONTROL NUMBER: 28-AS-20211119142340

FACILITY NAME:	BURBANK RETIREMENT VILLA EAST		FACILITY NUMBER:	198603136
ADMINISTRATOR:	SOKOLOWSKI, MICHAEL		FACILITY TYPE:	740
ADDRESS:	1900 GRISMER AVE		TELEPHONE:	(818) 843-3141
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	100	CENSUS: 98	DATE:	08/02/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Office Manager / Marili Barajas Administrator / Imelda Viilanueva		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident missed scheduled optometrist appointments while in care.

Staff did not address a resident's change in medical condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above-mentioned allegations of “Resident missed scheduled optometrist appointments while in care and Staff did not address a resident's change in medical condition”. Upon arriving at the facility, LPA met with Office Manager / Marili Barajas who assisted with the visit. LPA explained the purpose of this visit.

LPA Katrdzhyan conducted a prior visit to this facility on 11/29/21, in reference to the allegations listed above.

During the course of the investigation, interviews were conducted of various persons to include the Office Manager, Staff 1 (S1) and Residents 1 – 7 (R1 – R7). During visits conducted on 11/29/21 and 8/2/23, LPA toured a random selection of resident rooms. Also, copies of the following documents were obtained and reviewed in reference to R1; (Please see LIC 9099C for additional information)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) -98-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: 323-981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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-20211119142340

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 RETIREMENT VILLA EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 08/02/2023

NARRATIVE

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• Physician’s Reports dated: 7/13/20 and 3/22/22 • Preplacement Appraisal Information • Identification and Emergency Information • Consent for Emergency Medical Treatment • Release of Client/Resident Medical Information • Admission Agreement • Resident Roster • Personnel Report

The investigation revealed the following;

Allegation: Resident missed scheduled optometrist appointments while in care.
Based on interviews conducted, there were multiple statements obtained which were consistent and corroborated with the above-mentioned allegation. R1 had an appointment scheduled with an Optometrist sometime in October or November of 2021 (exact date unknown) and R1 ended up missing her appointment due to facility not providing transportation and failing to make arrangements for R1 to see her Optometrist. LPA discovered that there was no driver on the day of the appointment. Based on the investigation conducted, there was sufficient evidence found, proving the above-mentioned allegation to be true.

Allegation: Staff did not address a resident's change in medical condition.
R1 was admitted to Burbank Retirement Villa East (BRVE) on 7/17/2020. While reviewing the file for R1, LPA discovered that R1 had concerns related to her vision (Right Eye), prior to her admission at BRVE. On the summary report from Emerald Terrace Convalescent Hospital (ETCH), dated 6/26/202, it states “follow up with Ophthalmology due to Right Eye blindness”. While reviewing the Preplacement Appraisal for R1, facility staff documented R1’s vision as “good” and there was no indication regarding vision concerns involving R1. On the physician’s reports dated 7/13/20 and 3/22/22, R1 was listed as not having a visual impairment. During R1’s stay at BRVE, R1 had several appointments with the Optometrist due to decline/change in her vision, yet facility staff failed to update the changes in her medical condition and keeping the appraisal accurate. Based on interviews conducted and record reviews, there was sufficient evidence found, proving the above-mentioned allegation to be true.

Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) -98-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: 323-981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20211119142340

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 RETIREMENT VILLA EAST	FACILITY NUMBER: 198603136
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/16/2023 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.	1 2 3 4 5 6 7	Administrator will review Title 22 Regulations Section 87465 on Incidental Medical and Dental Care and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.
	8 9 10 11 12 13 14	This requirement is not being met as evidenced by: R1 had an appointment scheduled with an Optometrist sometime in October or November of 2021 (exact date unknown) and R1 ended up missing her appointment due to facility not providing transportation and failing to make arrangements for R1 to see her Optometrist. LPA discovered that there was no driver on the day of the appointment.	8 9 10 11 12 13 14
Type B 08/16/2023 Section Cited CCR 87463(a)(1-3)	1 2 3 4 5 6 7	Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition…	1 2 3 4 5 6 7	Administrator will review Title 22 Regulations Section 87463 on Reappraisals and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.
	8 9 10 11 12 13 14	This requirement is not being met as evidenced by: While reviewing the file for R1, LPA discovered that R1 had concerns related to her vision (Right Eye), prior to her admission at BRVE. On the summary report from Emerald Terrace Convalescent Hospital (ETCH), dated 6/26/202, it states “follow up with Ophthalmology due to Right Eye blindness”. While reviewing the Preplacement Appraisal for R1, facility staff documented R1’s vision as “good” and there was no indication regarding vision concerns involving R1. On the physician’s reports dated 7/13/20 and 3/22/22, R1 was listed as not having a visual impairment. During R1’s stay at BRVE, R1 had several appointments with the Optometrist due to decline/change in her vision, yet facility staff failed to update the changes in her medical condition and keeping the appraisal accurate.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) -98-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: 323-981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2021 and conducted by Evaluator Joe Katrdzhyan

COMPLAINT CONTROL NUMBER: 28-AS-20211119142340

FACILITY NAME:	BURBANK RETIREMENT VILLA EAST		FACILITY NUMBER:	198603136
ADMINISTRATOR:	SOKOLOWSKI, MICHAEL		FACILITY TYPE:	740
ADDRESS:	1900 GRISMER AVE		TELEPHONE:	(818) 843-3141
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	100	CENSUS: 98	DATE:	08/02/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Office Manager / Marili Barajas Administrator / Imelda Viilanueva		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
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5
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7
8
9

Staff do not properly maintain a resident's room.

Staff speak inappropriately towards a resident while in care.

INVESTIGATION FINDINGS:

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5
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7
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above-mentioned allegations of “Staff do not properly maintain a resident's room and Staff speak inappropriately towards a resident while in care”. Upon arriving at the facility, LPA met with Office Manager / Marili Barajas who assisted with the visit. LPA explained the purpose of this visit.

LPA Katrdzhyan conducted a prior visit to this facility on 11/29/21, in reference to the allegations listed above.

During the course of the investigation, interviews were conducted of various persons to include the Office Manager, Staff 1 (S1) and Residents 1 – 7 (R1 – R7). During visits conducted on 11/29/21 and 8/2/23, LPA toured a random selection of resident rooms.

(Please see LIC 9099C for additional information)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) -98-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: 323-981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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-20211119142340

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 RETIREMENT VILLA EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 08/02/2023

NARRATIVE

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The investigation revealed the following;

Allegation: Staff do not properly maintain a resident's room.
The details of this allegation states that the bedding in resident rooms are foul and rancid and the living quarters in resident rooms are unsanitary. There is a foul smell in bathrooms, dust and garbage underneath resident beds.
Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. LPA discovered that resident rooms are cleaned daily. During the process, housekeeping will take out the trash, sweep/mop, make resident beds, change the towels and clean the bathrooms. Resident bed sheets are changed once a week or as needed. Interviews conducted did not present concerns of resident rooms being unsanitary. During the visit conducted on 11/29/21, LPA toured resident rooms 206 and 220. During the visit conducted on 8/2/23, LPA toured resident rooms 235, 236, 204, 209, 102 and 108. During both visits, LPA observed resident rooms were clean and sanitary. There was no foul smell inside the rooms or inside the bathrooms. The trash bins were covered with a lid and were empty. The bed sheets and linens were observed to be clean and no dirt or trash was observed underneath resident beds. Based on the investigation conducted, there is insufficient evidence to support the above-mentioned allegation to be true.

Allegation: Staff speak inappropriately towards a resident while in care.
The details of this allegation states that S1 is verbally abusive towards residents and makes derogatory comments.
Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. Statements obtained from residents described S1 as being nice and helpful towards residents and denied being verbally abused by S1. During the interview of S1, S1 denied being verbally abusive or making derogatory comments towards residents. Based on interviews conducted, there is insufficient evidence to support the above-mentioned allegation to be true.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) -98-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: 323-981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5