198603136-5-10-2024-31-AS-RORN-D5AP7Z-20240515110446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:02:39 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
08/08/2023 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 31-AS-20230808125834

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: 87	DATE:	05/10/2024
		UNANNOUNCED	TIME BEGAN:	09:21 AM
MET WITH:	Executive Director Imelda Villanueva		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained unexplained injuries while in care.

INVESTIGATION FINDINGS:

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

On 05/10/24 at 09:21 am Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit to render findings. LPA met with Executive Director Imelda Villanueva as the Purpose of today’s visit was explained.

The investigation consisted of the following: On 05/08/24 LPA Villegas obtained copies of the following; staff and resident roster(s), a list of all residents that require assistance with bathing/ADL log, facility rules. LPA also obtained copies of the following for R1-R4; Facesheet, admission agreement, physicians report, needs and service plan, MAR for April, May, and June 2023. On 05/08/24 LPA Villegas interviewed residents #5-12 (R5-R12), and staff #1-4 (S1-S4). On 05/09/24 LPA interviewed Executive Director (ED) and requested incident report pertaining to the allegation above.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: 424-544-1075
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 2

Control Number 31-AS-20230808125834

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

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

Allegation: Resident sustained unexplained injuries while in care.

It is being alleged that resident obtained an un-witnessed fall on 08/04/23 that resulted in a swollen left cheek, and a bruised eye. On 05/09/24 LPA interviewed ED regarding the allegation above, Ed denied the allegation above and reported being unaware of residents fall until it was reported by Norwalk community hospital. ED continued to report that resident believes resident can still walk and resident tries to get up without assistance. ED reports staff conduct rounds every two hours to ensure resident care and safety. On 05/08/24 between 10:30 am-11:45 am, LPA interviewed R5-R12 regarding the allegation above, 8 of 8 residents interviewed denied the allegation and reported not sustaining any injury due to staff neglect. On 05/08/24 LPA was unable to interview R1 as R1 did not wish to conduct interview. On 05/09/24 LPA attempted to interview W1 but was unable to make any contact. On 05/08/24 between 12:18 pm -1:17 pm, LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above. 4 of 4 staff interviewed reported rounds are conducted every 2 hours, however report residents have call buttons residents can use if residents require assistance. On 05/10/24 LPA obtained a copy of LIC 624 dated 08/09/23 that states facility staff sent R1 to Norwalk Community hospital for further evaluation. Per LIC 624, while at the hospital R1 had no recollection of un-witnessed fall.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with Executive Director Imelda Villanueva, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: 424-544-1075
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 2