198603136-5-10-2024-31-AS-RORN-D5HV6T-20240522161003

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:04:18 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
06/30/2023 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 31-AS-20230630094119

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:	09:19 AM
MET WITH:	Executive Director Imelda Villanueva		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff do not distribute resident's medications as prescribed.
Staff do not meet resident's dietary needs.
Staff do not assist resident with bathing.

INVESTIGATION FINDINGS:

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On 05/10/24 at 9:10 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), facility menus for April, May, and June 2023, a list of all residents that require assistance with bathing/ADL log, list of residents who have dietary restrictions/ modified diets, and 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, June, and July 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 left a voicemail to dietary director.

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 3

Control Number 31-AS-20230630094119

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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Allegation: Staff do not distribute resident's medications as prescribed.

It is being alleged that staff do not distribute residents’ nausea medication as prescribed for residents dialysis. On 05/09/24 LPA interviewed ED regarding the allegation above, Ed denied the allegation above and reported all medications are administered by med techs as prescribed by physician. Per ED, medications will only be withheld from residents if the physician has ordered medications to be held.On 05/08/24 between 10:30 am-11:25am, LPA interviewed R5-R12 regarding the allegation above, 8 of 8 residents interviewed denied the allegation and reported receiving medication daily. LPA was unable to interview R1 as R1 is no longer receiving care at Burbank Senior Villa East. On 05/08/24 between 12:20pm-1:17pm, LPA interviewed S1-S4 regarding the allegation above, 3 of 4 staff interviewed denied the allegation above and reported that med techs administer medications, and that no medications are withheld from residents. 3 of 4 staff reported that when a resident refuses medication, med techs will take back the medication, wait 10-15 minutes and offer the medication once again, if a resident continues to refuse medications staff will document the refusal. 1 of 4 staff interviewed denied the allegation above and reported med tehcs administer medications, however 1 of 4 staff interviewed reports having no knowledge of medication procedures. On 05/09/24 LPA conducted a medication administration review for 8 residents and did not observed any discrepancies. On 05/09/24 LPA reviewed MAR for R1, no discrepancies were observed as MAR has documentation reporting PRN medication is provided when requested.

Allegation: Staff do not meet resident's dietary needs.

It is being alleged that staff are not providing resident with lunch when resident leaves the facility for dialysis. On 05/09/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above and reported that staff offer to have meals packed when a resident will be out of the facility for medical appointments. On 05/08/24 between 10:30 am-11:25am, LPA interviewed R5-R12 regarding the allegation above, 8 of 8 residents interviewed denied the allegation above and reported having all necessary meals. On 05/08/24 between 12:20 pm-1:17pm, LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above, and reported that residents dietary needs are being met. On 05/08/24 LPA toured facility kitchen and observed menus posted, and enough food supply for facility size. LPA was unable to interview R1 as R1 is no longer receiving care at Burbank Senior Villa East. On 05/10/24 LPA reviewed physicians report that indicated R1 required a renal diet while in care. On 05/10/24 at 11 am LPA spoke to W1 regarding the allegation above, per W1 the facility kitchen will provide alternative meals for resident to accommodate dietary needs. W1 continued to report that menus are reviewed weekly and are

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 3

Control Number 31-AS-20230630094119

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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adjusted accordingly.

Allegation: Staff do not assist resident with bathing.

It is being alleged that that staff do not bathe resident twice per week as required. On 05/09/24 LPA interviewed ED regarding the allegation above, Ed denied the allegation above and reported that the facility has an ADL log which staff will use to document what and when residents are showered. ED continued to report that residents are provided with showers two times a week unless a resident refuses. On 05/08/24 between 10:30 am-11:25am, LPA interviewed R5-R12 regarding the allegation above, 8 of 8 residents interviewed denied the allegation and reported staff assist with showers 2 times a week or more if needed. LPA was unable to interview R1 as R1 is no longer receiving care at Burbank Senior Villa East. On 05/08/24 between 12:20 pm-1:17pm, LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above. 4 of 4 staff interviewed reported residents are assisted with showers 2 times a week which is documented on the facilities ADL log. On 05/09/24 LPA reviewed ADL log for April, May, and June 2023 and observed that residents are provided with showers regularly, LPA reviewed shower log for R1 and did not observe any discrepancies, shower log shows R1 is provided with showers regularly.

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(s) 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)

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