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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 05/10/2024
Date Signed: 05/10/2024 09:20:03 PM

Unsubstantiated


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
09/19/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230919092517
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: 87DATE:
05/10/2024
UNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Imelda Villanueva TIME COMPLETED:
12:47 PM
ALLEGATION(S):
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Staff did not order residen's oxygen tank.
Resident sustained a stage 1 pressure injury due to staff neglect.
Staff are retaliating against resident due to authorized representative asking questions about resident's care.
Resident's a/c is in disrepair.
INVESTIGATION FINDINGS:
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On 05/10/24, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to this facility and was greeted by Administrator (A1: Imelda Villanueva). LPA explained the purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations.

The investigation consisted of the following: An initial 10-Day visit was conducted by (LPA) Antonia Alvizar on 09/22/23 who met with Administrator Villanueva. (LPA) Dabuet requested copies of files for resident #1 (R1’s) ID and Emergency Information (dated: 08/17/23) Admissions Agreement (dated: 08/17/23), Physicians Report LIC 602A (dated: 08/07/23), Preplacement Appraisal Information LIC 603 (dated: 0728/23), Skilled Home Health Inc Certification and Plan of Care (dated: 0823/23 – 10/21/23), Skilled Home Health Inc, Progress Notes (dated: 08/22/23 – 10/21/23), Department of Health Care Services (DHCS) Individual Service Plan (dated: 06/02/23), Consent for Emergency Medical Treatment (dated: 08/17/23), Facility Resident Roster (dated: 05/02/24) and Personnel Report LIC 500 (dated: 05/02/24).
(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
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 6
Control Number 31-AS-20230919092517
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 SENIOR VILLA EAST
FACILITY NUMBER: 198603136
VISIT DATE: 05/10/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff did not order resident’s oxygen tank.

The details of the complaint alleged that resident #1 (R1) was without an oxygen tank for several days. The complainant reported that an oxygen tank was required when (R1) was transferred from a skilled nursing facility (SNF) on 08/16/23. (R1) was sent without oxygen by the (SNF) and informed that Burbank Senior Villa East would be providing the equipment. The complainant added that (R1) again did not have an oxygen tank on 09/18/23 and that (R1’s) level was down 70%.

According to resident #1 (R1’s) Identification and Emergency Information LIC 601 (dated: 08/17/23) and Admissions Agreement (dated: 08/17/23), (R1) was admitted at Burbank Senior Villa East on 08/17/23. A voluntary terminated of residency on 10/31/23 by (R1) due to needing a higher level of care.

On 09/22/23, between 09:00 am – 03:00 pm, Licensing Program Analyst (LPA) Antonia Alvizar interviewed resident #1 (R1) using Language Link Translator Operator #16459. (R1) stated that staff did order an oxygen tank and no further information was provided.

On 05/08/24, between 10:30 am – 11:45 am, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (8) out of (9) residents #2 - #9 (R2-R9) claimed to have no issues with oxygen tank as it is not a prescribed equipment authorized by their medical physician. (R7) a former oxygen tank user reported never having issues obtaining an equipment through home health or primary physician.

On 05/08/24, between 12:20 pm – 01:17 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (4) out (4) staff #1-#4 (S1-S4) who denied knowing (R1) not having an oxygen tank on 08/17/23 and 09/18/23. (S1-S4) acknowledged that (R1) required the equipment and that home health with (R1’s) primary physician is responsible for ordering the equipment. (S1-S4) stated (R1) was never without access to an oxygen tank. (S1-S4) stated if (R1’s) physician's order did not arrive timely, (R1) would be provided with a substitute supplied by the facility.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20230919092517
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 SENIOR VILLA EAST
FACILITY NUMBER: 198603136
VISIT DATE: 05/10/2024
NARRATIVE
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On 05/08/24, between 10:30 am – 11:45 am, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (8) out of (9) residents #2 - #9 (R2-R9) described to have never had issues with their air conditioning units their rooms or a/c units in the common areas.

On 05/08/24, between 12:20 pm – 01:17 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (4) out (4) staff #1-#4 (S1-S4) recollection on this matter is that (R1’s) a/c unit never had issues. (S1-S4) there is no work order for maintenance for repair.

On 05/09/24, between 11:09 pm – 11:51 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed administrator #1 (A1). (A1) informed that (R1’s) air conditioning unit always worked. Each room is equipped with programmable thermostat. Often the residents will tinker with the unit or remove batteries preventing proper operation of the unit. According to (A1) most of rooms have clear thermostat cover with lock. (R1’s) a/c unit did not have lock box cover.

On 05/08/24, between 01:10 pm – 1:31 pm, Licensing Program Analyst (LPA) inspected (R1’s) room #112, #224, #225, #226, #227 and #228 and tested the air conditioning units in working condition. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above.

(LPA) Ernand Dabuet could not obtain additional statements related to the allegations in this complaint from (R1) due to unreturned calls.

Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegations mentioned in this complaint. 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.


No deficiencies were cited.

An exit interview is conducted with Imelda Villanueva and a copy of the report is provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 31-AS-20230919092517
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 SENIOR VILLA EAST
FACILITY NUMBER: 198603136
VISIT DATE: 05/10/2024
NARRATIVE
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On 05/09/24, between 11:09 pm – and 11:51 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed administrator #1 (A1). (A1) claimed this allegation is false. (A1) stated that (R1) was admitted to the facility on 08/17/23 with no oxygen tank. The facility provided a substitute for (R1) the same day until (R1) was admitted on home health on 08/23/23. (A1) stated that a family representative for (R1) preferred a portable oxygen tank that is not covered through (R1’s) insurance which required an out-of-pocket deductible, and that the family did not want to pay the extra cost. (A1) explained while the family was contemplating the decision, it held up the home health’s request for equipment. (R1) was supplied with a substitute oxygen tank in place by the facility until home health equipment arrived. According to (A1) during the treatment of (R1) at the facility, (R1) was never provided with a portable oxygen tank and was never out of the equipment.

A review of Skilled Home Health, Inc. Admission Order (dated: 08/23/23) indicated Oxygen 2 liters were ordered as confirmed the facility. Based on the information gathered, there is no sufficient evidence to support the allegation mentioned above.

Allegation #2: Resident sustained a stage 1 pressure injury due to staff neglect.

A pressure injury stage 1 is alleged to have occurred to resident #1 (R1). According to the complainant due to staff neglect, (RI) sustained about 2-3 mm wound but not enough to warrant hospitalization for (R1).

On 09/22/23, between 09:00 am – 03:00 pm, Licensing Program Analyst (LPA) Antonia Alvizar interviewed resident #1 (R1) using Language Link Translator Operator #16459. (R1) claimed did not sustain a pressure injury. (R1) declared not to have any pressure injury.

On 05/08/24, between 10:30 am – 11:45 am, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (8) out of (9) residents #2 - #9 (R2-R9) claimed never had any types of wounds while in care at this facility. (R2-R9) did not know any residents being cared for with any pressure injuries.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20230919092517
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 SENIOR VILLA EAST
FACILITY NUMBER: 198603136
VISIT DATE: 05/10/2024
NARRATIVE
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On 05/08/24, between 12:20 pm – 01:17 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (4) out (4) staff #1-#4 (S1-S4) claimed to not know about (R1) with pressure injury. (S1-S4) claimed (R1) was on home health and that the home health nurse would have been the primary source to address any wounds. (S1-S4) reported that incontinent residents are being repositioned, and changed diapers every two hours, or as required. Body checks are performed during these services and are documented if any change in condition.

On 05/09/24, between 11:09 pm – 11:51 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed administrator #1 (A1). (A1) claimed this allegation is untrue. (A1) explained that (R1) was diagnosed with Dermatitis according to the Department of Health Care Services (DHCS) Individual Service Plan (dated: 06/02/23) a condition that caused inflammation in the skin and was admitted to the facility with a simple skin tear originated from the (SNF). (R1) was under Skilled Home Health, Inc., effective 08/23/23 until (R1’s) was discharged on 10/31/23. Skilled Home Health assessed and treated the wound with a wound specialist. (A1) claimed the facility staff were only responsible for (R1’s) non-medical care since the facility is a non-medical care facility.

A review of Skilled Home Health, Inc. records revealed (R1) was treated for a skin condition by a wound care specialist (dated: 09/20/23, 09/25/23, 10/02/23, 10/04/23, and 10/09/23). Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above.

Allegation #3: Staff are retaliating against resident due to authorized representative asking questions about resident’s care.

It is alleged that (A1) retaliated against (R1’s) authorized representative due to inquiring questions about (R1’s) care. The complainant reported paramedics were dispatched as a retaliation due to questions about (R1’s) pressure injury. The complainant did not offer further information on this matter.

On 09/22/23, between 09:00 am – 03:00 pm, Licensing Program Analyst (LPA) Antonia Alvizar interviewed resident #1 (R1) using Language Link Translator Operator #16459. (R1) indicated that staff treated (R1) well. (Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20230919092517
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 SENIOR VILLA EAST
FACILITY NUMBER: 198603136
VISIT DATE: 05/10/2024
NARRATIVE
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On 05/08/24, between 10:30 am – 11:45 am, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (8) out of (9) residents #2 - #9 (R2-R9) reported are complimentary of the staff and they have not experienced any retaliation from staff including (A1).

On 05/08/24, between 12:20 pm – 01:17 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (4) out (4) staff #1-#4 (S1-S4) and asserted this allegation is false. (S1-S4) stated they treated residents and family representatives professionally. (S1-S4) stated this type of behavior is considered harassment and the facility has a zero-tolerance policy for any type of harassment.

On 05/09/24, between 11:09 pm – 11:51 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed administrator #1 (A1). (A1) claimed this allegation is incorrect. (A1) there no retaliation happened with any residents or family representatives. (A1) explained that 911 was called on 09/11/23, the request was made by home health due to (R1) experiencing shortness of breath (SOB) and Emesis and had nothing associated with (R1’s) pressure injury. (A1) stated to have been accessible and accommodating to (R1’s) authorized family representatives when inquiries of (R1’s) care.

A review of Skilled Home Health, Inc. records (dated: 09/11/23) revealed 911 was dispatched and home health services were placed on hold. Services resume for (R1’s) care after hospital discharge within an episode of care. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above.

Allegation #4: Resident's a/c is in disrepair.

It is alleged that resident #1 (R1’s) air conditioning (a/c) was not operable. The complainant reported that it was 105 degrees in Los Angeles and these vulnerable residents need a/c. The complainant did not offer additional information on this matter such as a date, time or individuals involved.

On 09/22/23, between 09:00 am – 03:00 pm, Licensing Program Analyst (LPA) Antonia Alvizar interviewed resident #1 (R1) using Language Link Translator Operator #16459. (R1) expressed that a/c worked.

(Evaluation Report LIC 9099-C)

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6