198603136-4-29-2024-31-AS-NGID-D5AM5A-20240515091757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 04/29/2024
Date Signed: 04/29/2024 03:34:01 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
04/19/2024 and conducted by Evaluator Huma Rahimi

COMPLAINT CONTROL NUMBER: 31-AS-20240419091845

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: 90	DATE:	04/29/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Imelda V. Villanueva, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee does not keep facility elevators maintained in operating condition
Staff did not ensure a resident attended a scheduled appointment

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced initial complaint visit. LPA met with the Administrator, Imelda V. Villanueva, and disclosed the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:15 AM, LPA requested resident and staff roster. At 10:20 AM, LPAs requested copies of pertinent information which include, but not limited to Physician’s Report, Addmission Agreement, Hospital Discharge Papers, Appraisal Needs and Services Plan, Invoices, and etc., relevant to the investigation. At approximately 10:30 AM, LPA conducted a physical plant tour. Between 11:45 AM – 2:30 PM, LPA conducted an interview with the Administrator, Maintenence Director, three (3) Staff, an Home Health Nurse, and nine (9) out of ten (10) residents who were able to communicate.
Continue on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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 2

Control Number 31-AS-20240419091845

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: 04/29/2024

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
26
27
28
29
30
31
32

Licensee does not keep facility elevators maintained in operating condition:
It's alleged that the elevator had been out for six months to a year. During the visit, LPA was able to use the elevator to go upstairs and observed the elevator being operational and working without any problem. Additionally, LPA reviewed Special Incident Reports (SIRs) for the elevator being out for one (1) or two hours to a day for three (3) different occasions due to a leak in hydraulic oil. Moreover, the facility has a monthly scheduled service with Elevator Support Services, Inc company to maintain and service the elevator on a regular basis. Interviews with nine (9) out of ten (10) residents who were able to communicate, the Administrator, Maintenance Director, and three (3) staff confirmed that the elevator was out for a very short period; however, it was repaired and operational right away. Based on the observation, document review, and interviews the above allegation is unsubstantiated at this time.

Staff did not ensure a resident attended a scheduled appointment:
It is alleged that on 04/18/2024, resident # 1 (R1) missed their scheduled doctor appointment due to the lack of transportation. To investigate the above allegation LPA reviewed documents and it was revealed that R1 did not have a scheduled appointment on 04/18/2024, with Olive View, UCLA Medical Center. Moreover, LPA was informed that the facility provides transportation services to all residents three (3) days a week (Mondays, Wednesdays, and Fridays). Even though the facility does not provide transportation services on Thursdays, the facility still accommodated to take R1 to an Emergency Room for medical evaluation. Additionally, interviews with nine (9) out of ten (10) residents who were able to communicate confirmed that they never missed any scheduled doctor’s appointments, and the facility provides them with transportation services as needed. Based on the documents review and interviews the above allegation is unsubstantiated at this time.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2