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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 05/14/2024
Date Signed: 05/15/2024 10:32:44 AM

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
11/02/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20231102163819
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: 88DATE:
05/14/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Imelda Villanueva TIME COMPLETED:
12:47 PM
ALLEGATION(S):
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Staff did not provide requested records to resident's responsible party.
Staff falsified documents.
Staff did not provide resident proper notice of rate increase.
INVESTIGATION FINDINGS:
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On 05/14/24, 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 (LPAs) Gary Tan, Gina Saucedo and Leslie Castaneda on 11/03/23 who met with Regional Director Nirjara Acharya. (LPA) Dabuet requested copies of files for resident #1 (R1’s) ID and Emergency Information (dated: 05/11/22) Admissions Agreement (dated: 05/11/22), Physicians Report LIC 602A (dated: 05/10/22), Preplacement Appraisal Information LIC 603 (dated: 01/29/22), Functional Capability Assessment LIC 9172 (dated: 05/11/22), Arkansas Teacher Retirement System Retirement Income Verification (dated: 07/27/22), Burbank Senior Villa East Notification Letter Services Increase (date: xx xx xx), Resident Council Meeting Log (dated: 09/25/23), Burbank Senior Villa East Invoice (dated: 10/2023), Resident Detail Ledger (dated: 11/2022 thru 06/2024), Payer Open Charges (dated: 11/2022 thru 11/2023), Resident Summary Ledger (dated: 11/2022 thru 06/2024), Lebleuchateau, Inc. Statement (dated: 04/30/24), Supplemental Security Income checks, Personal Check (dated: 03/04/24),Facility Resident Roster (dated: 05/10/24) and Personnel Report LIC 500 (dated: 05/10/24). (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: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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 4
Control Number 31-AS-20231102163819
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: 05/14/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff did not provide requested records to resident’s responsible party.

The details of the complaint alleged that facility staff failed to provide records requested by the responsible party for resident #1 (R1). The complainant reported on multiple occasions requesteed a ledger documenting the payments made by (R1) to ensure accuracy. The complainant claimed to have been informed that the records were located at the corporate office.

According to resident #1 (R1’s) Identification and Emergency Information LIC 601 (dated: 05/11/22) and Admissions Agreement (dated: 05/11/22), (R1) was admitted at Burbank Senior Villa East on 05/11/22.

On 05/10/24, between 10:37 am – 11::01 am, the Department interviewed resident #1 (R1). (R1) stated that this matter has been resolved and had received all the necessary documents requested.

On 05/10/24, between 11:05 am – 11:31 am, the Department interviewed business manager staff #1 (S1). (S1) claimed to have provided (R1’s) responsible party with the following: (R1’s) Payer Ledger, Retirement Income Verification, Statement Invoice (dated: 10/2023), Notice of Rate Increase Letter, Payer Detail Ledger (11/22 thru 11/23), Copies of SS1 and SSA checks total amount of $1327.82, Personal check in amount of $400 and Admissions Agreement on 11/02/23 through an email process. The request was made by email from (R1’s) responsible party on 10/23/23 and evidence of email communications from (S1) and the responsible party on 10/27/23 and 11/02/22. (S1) confirmed that the facility cooperated with (R1’s) responsible party and provided all the necessary records requested. However, the (R1’s) ledger for prior months beginning 05/22 through 10/22 were in another accounting software program with the facility’s corporate office, and will take some additional days to obtain a copy. (S1) reported that (R1’s) responsible party did not request again for the statement aside from what (S1) provided on 11/02/23, and considered request to have been fulfilled.

A review of (R1’s) general ledger indicated (R1) was admitted with the amount for basic service of $1231.77 on 05/11/22. A reassessment of (R1’s) Medi-Cal with a shared cost brought the basic services to increase by $1344.82 effective 01/01/23. Effective 01/01/24 (R1’s) basic services increased to $1398.07. (R1) continued to make payments of $1,200.77 and $1327.82 and not the full amount which resulted in an open totaling balance of $215 as of 10/27/23. (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: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20231102163819
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: 05/14/2024
NARRATIVE
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According to (S1), (R1) has a monthly retirement benefit from Arkansas Teacher Retirement for $185.00. (S1) stated the facility had no access to this retirement benefit in which goes directly to (R1’s) checking account associated with (R1’s) family member. Evidence of payment for the remaining balance owed by (R1) was paid in full on 03/04/24 by (W1) check #6853. Currently, (R1) has a zero outstanding balance as of 05/14/24.

The Department reviewed all the records provided to (R1’s) responsible party along with the Statement from Lebleuchateau, Inc. (dated: 04/30/22 through 11/01/22) the missing statement (R1) claimed not to have received and found to be complete and accurate. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above.

Allegation #2: Staff falsified documents.

It is alleged the admission agreement signed on 5/11/2022 by (R1) was altered. According to the complainant the (date and basic rate amount were modified).

On 05/10/24, between 11:05 am – 12:37 pm, the Department interviewed administrator #1 (A1) and business manager staff #1 (S1). (A1-S1) both denied falsifying any service records for residents.

An examination of (R1's) Admission Agreement, provided by the facility and compared it to the copy provided by (R1's) responsible party, appeared to have no modifications, the copy is identical, complete, and accurate. Furthermore, resident #5 (R5’s) Admission Agreement was reviewed in comparison to (R1’s) Admission Agreement, which revealed no differences and no modifications. Based on the information gathered, there is no sufficient evidence to support the allegation mentioned above.

Allegation #3: Staff did not provide resident proper rate increase.

The details of the complaint alleged the staff failed to provide resident #1 (R1) with a proper notice of a rate increase. According to the complainant the facility provided a Notice Letter of Rate Increase to (R1) on 10/27/23, which appeared with no date in the letter and gave the impression of being modified with a whiteout.

(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: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20231102163819
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: 05/14/2024
NARRATIVE
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On 05/10/24, between 10:37 am – 11::01 am, the Department interviewed resident #1 (R1). (R1) stated that this matter has been rectified. However, when presented with a copy of a Notice Letter of Rate Increase for 2024, (R1) could not recall ever receiving a copy.

On 05/10/24, between 11:05 am – 11:31 am, the Department interviewed business manager staff #1 (S1). (S1) provided a copy of the Notice Letter of Rate Increase that was presented to (R1) in late October 2023. (S1) claimed that all residents received the Notice Letter of Rate Increase effective 01/01/24, in person or it was placed inside their mailboxes.

On 05/10/24, between 11:32 am – 12:05 pm, the Department interviewed (7) out of (7) residents #2 - #8 (R2-R8). Four (4) out of seven (7) claimed to have received the Notice Letter of Rate Increase. Three (3) out of seven (7) could not recall or claimed not to have received the notice.

On 05/10/24, between 12:10 pm – 12:37 pm, the Department interviewed administrator #1 (A1). (A1) verified that it was (A1’s) signature on the Notice Letter of Rate Increase distributed to all the residents residing at Burbank Senior Villa East. Nevertheless, (A1) did not observe that a date was omitted from the letter generated by the business office. (A1) reported aside from a written notice given to the residents, the topic of rate increase for 2024 was presented during the Resident Council Meeting held on 09/25/24.

A review of the Notice Letter of Rate Increase revealed it did not have a date, though it did not appear to be altered. Resident Council Meeting Log indicated that the topic of rate increase for January 2024 was discussed at the meeting. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. The Department could not obtain additional statements related to the allegations in this complaint from family member (W1) 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: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4