198603136-5-10-2024-31-AS-RORN-D5GPD2-20240521111251

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:01:35 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
01/16/2024 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 31-AS-20240116144428

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:	09:20 AM
MET WITH:	Executive Director Imelda Villanueva		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff does not prevent resident from disturbing another resident.

INVESTIGATION FINDINGS:

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On 00/00/24 at 9:20 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) 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, 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).

The investigation revealed the following:
Allegation: Staff does not prevent resident from disturbing another resident.

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)

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Control Number 31-AS-20240116144428

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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It Is being alleged residents are having loud conversations outside of peer’s bedroom while peer is sleeping. On 05/09/24 LPA interviewed ED regarding the allegation above, Ed denied the allegation above. Per ED, residents have the right to gather in common areas but are asked to not to speak so loudly when outside of a peer’s bedroom. ED continued to report that staff will offer a different common area with privacy for residents to gather. On 05/08/24 between 12:18pm-1:17pm, LPA interviewed R5-R12 regarding the allegation above, 8 of 8 residents interviewed denied the allegation and reported feeling safe at the facility. LPA was unable to interview R1 as R1 did not want to be interviewed. On 05/08/24 between 12:20pm-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 rounds are conducted every 2 hours, and that if needed there are de-escalation procedures that take place to ensure conformability and safety. On 05/08/24 LPA conducted a tour of the facility and did not observe any immediate health and safety concerns.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation 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)

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