198603136-1-8-2024-31-AS-NMAN-D2EPH5-20240213101923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 01/08/2024
Date Signed: 01/08/2024 05:27:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
12/29/2023 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20231229132112

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: 94	DATE:	01/08/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Executive Director, Imelda Villanueva		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility did not take necessary precautions to prevent the spread of COVID-19

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Antonia Alvizar made an unannounced complaint visit for the above stated allegation. LPA met the Executive Director, Imelda Villanueva and explained the reason for the visit.

Facility did not take necessary precautions to prevent the spread of COVID-19
It is alleged that several residents have tested positive for COVID-19 they are in common areas together and not in quarantine. Staff diagnosed with COVID-19 were required to work.

To investigated this allegation at 10:20 a.m., LPA conducted a physical plant tour. At 11:00 a.m., LPA interviewed residents, staff and about 2:00 p.m. reviewed facility records. LPA obtained copies of staff and resident roster, unusual incident reports and pertinent documents relevant to the investigation. During inspection, LPA Alvizar interviewed six (6) residents that had tested positive for COVID -19, two (2) randomly selected out of nine-four (94) residents including resident #1 (R1).
Continue on LIC 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

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 31-AS-20231229132112

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BURBANK SENIOR VILLA EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 01/08/2024

NARRATIVE

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Continuation from LIC 9099

Upon inspection, LPA observed that some staff were wearing mask. Residents that tested positive for COVID -19 interviewed during this visit indicated that mask were provided, meals were provided in room, re-tested for COVID -19, and asked to stay in room until they don’t have the symptoms. The randomly selected residents indicated that mask were provided and weekly COVID-19 were conducted.

R1 agree that Administrator mandated all residents and staff to wear a mask and also provided mask. R1 also agreed that Administrator request all residents to be tested for COVID-19 weekly. LPA conducted interview with Administrator and four (4) staff. Interviews indicated that facility is following COVID -19 protocol for both residents and staff that tested positive for COVID -19. Staff #1 (S1) that tested positive for COVID -19 said that could not work until obtaining a negative test result. Administrator indicated that all staff testing positive for COVID -19 are mandated not to work at all until test negative then they can return to work.

Staff and residents interviews revealed that facility did take necessary precautions to prevent the spread of COVID-19. Record review revealed that on 12/26/2023 facility tested resident for COVID -19 using PrimeLab test results. Administrator indicated upon learning of positive COVID -19 residents test results. Staff provided mandated positive COVID -19 residents to isolated, provided mask to all residents and staff and followed COVID -19 protocol. On 01/03/2024 facility tested residents for COVID – 19 and results were negative some residents refused to be tested again because they had no symptoms.

Based on inspection, interviews and record review there is an insufficient 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: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC9099 (FAS) - (06/04)

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