198603136-5-16-2024-31-AS-RORN-D5GP88-20240521110507

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 05/16/2024
Date Signed: 05/16/2024 12:31:31 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
09/11/2023 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230911081750

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: 88	DATE:	05/16/2024
		UNANNOUNCED	TIME BEGAN:	11:39 AM
MET WITH:	Imelda Villanueva		TIME COMPLETED:	12:32 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not accord resident privacy.
Staff are not assisting resident with care needs.

INVESTIGATION FINDINGS:

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

On 05/08/24, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted a subsequent unannounced visit to the facility and was greeted by Marili Barajas, Business Office Manager. LPA explained the purpose of this visit is to gather additional information and deliver findings for the allegations mentioned above.

The investigation consisted of the following: An initial complaint visit was completed by LPA Antonia Alvizar on 09/11/2023. A subsequent visit was completed by LPA Perry Scott on 05/08/2024. LPAs investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R10). Resident/Staff Roster, Admission Agreement, Needs and Service Plan, Face sheets/ID and Emergency Information, Pre-Appraisal, Physician's Report, and the Medication Administration Record for R1 were obtained from the facility.

Report continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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-20230911081750

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: 05/16/2024

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

The investigation revealed the following: Allegation #1- Staff do not accord resident privacy.

The details of the complaint alleged that the facility does not give the resident privacy and the staff walks in on them without notice when the resident is changing or taking a shower. On 05/08/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Staff do not accord resident privacy. All staff (S1-S4) stated that R1 and all residents are accorded privacy in their everyday lives. Staff further state that when they must enter the resident’s room, they knock first to alert them that they are entering the room. And when they do enter, they are only there to check on the well-being of the resident, to clean the room, assist the resident with their personal care needs, or to assist the resident with their activities of daily living. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not accord resident privacy. Residents stated that they did not have any problems with the staff giving them their privacy in their room or to have a private conversation with other residents or staff. And that the staff knocks before they come into their room and announces who they are and why they are here.

Based on interviews, there is insufficient evidence to support the allegation that Staff do not accord resident privacy. 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.

Allegation # 2- Staff are not assisting resident with care needs.

The details of the complaint alleged that the facility did not assist the resident with care needs. On 05/08/24, from 09:30am-02:00pm, LPA interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Staff are not assisting resident with care needs. All staff (S1-S4) stated that R1 and all residents are given assistance with their care needs and according to their care plan. Staff stated that R1 was independent and needed minimal assistance with their care needs. However, the staff stated that when R1 needed assistance with personal care needs or assistance with ADL’s, the staff was there to provide the resident with anything the resident was incapable of doing by themselves. LPA reviewed the Preplacement Appraisal dated 05/21/23 and the Physicians Report dated 05/08/23 and observed that the resident needed minimal assistance with personal care needs. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff are not assisting resident with care needs. Residents stated that they were happy with the care and supervision being provided to them, and that their personal care needs are being met by the staff. They also stated that whenever they ask for assistance from the staff, it is given.

Report continued on LIC9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230911081750

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: 05/16/2024

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

Based on interviews, there is insufficient evidence to support the allegation that Staff are not assisting resident with care needs. 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.

No deficiencies were cited.

An exit interview was conducted with Imelda Villanueva, Administrator, and a hard copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3