198603136-11-20-2023-31-AS-NMAN-D2DSTD-20240212130919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 11/20/2023
Date Signed: 11/20/2023 05:28:30 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.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
11/13/2023 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20231113162002

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: 97	DATE:	11/20/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director, Imelda Villanueva		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Resident's bathroom is in disrepair
Staff do not provide residents with towels

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Antonia Alvizar made an initial complaint visit to investigation of the above stated allegations. LPA met the Executive Director (ED), Imelda Villanueva and explained the reason for the visit.

1. Resident's bathroom is in disrepair.
2. Staff do not provide residents with towels.

It is alleged that room #209 bathroom does not have a shower head and R1 is unable to take a shower.
To investigate these allegations, At 10:15AM LPA requested resident and staff roster. LPA and ED conducted physical plant tour at 10: 30AM, requested copies of R1’s file which include the following documents: Emergency Information, Physician Rport, Individual Service Plan, and documents relevant to the investigations at 11:00AM and interviewed ED and three (03) staff and ten (10) residents randomly selected between 10:45:00AM to 3:30PM.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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 31-AS-20231113162002

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: 11/20/2023

NARRATIVE

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During physical plant tour LPA Alvizar inspected room #209 and observed a shower head operating perfectly fine. R1 indicated that bathroom has a shower head and is able to take a shower. Staff interviews revealed that residents have not complaint about bathrooms being in disrepair. Ten (10) out of ten (10) residents stated that they have a working shower head.

Based on inspection, observation and interviews, there is no sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

2. Staff do not provide residents with towels.

It is alleged that staff has not brought any towels to R1.

To investigate this allegation LPA conducted interviews. R1 indicated staff have provided towels but it took a while before receiving them. Staff interviews revealed that residents are always provided towel plus additional towels upon request. Ten (10) out of ten (10) residents stated that staff always provide a towel but sometimes staff take a little longer then expected. Overall, staff do provide clean towels when requested. LPA observed caregiver’s cart filled with clean towels during today’s visit.

Based on inspection, observation and interviews, there is no sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No immediate Health and Safety hazard is noted during this visit.

Exit interview conducted and a copy of the report was provided to Villanueva.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

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