<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 05/16/2024
Date Signed: 05/16/2024 01:32:18 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
09/19/2023 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230919142727
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:
05/16/2024
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Marili BarajasTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure resident has adequate storage space for personal belongings.
Resident was not accorded assistance by staff after having fallen.
Staff does not ensure resident is accorded dignity in her personal relations ships with staff, residents.
Staff do not ensure resident is spoken to in an appropriate manner.
Staff do not ensure medications are dispensed as prescribed to resident in care.
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 09/22/2023. A subsequent visit was completed by LPA Perry Scott on 05/08/2024. LPA 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 HammondTELEPHONE: (424) 544-1075
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: 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 4
Control Number 31-AS-20230919142727
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 does not ensure resident has adequate storage space for personal belongings.

The details of the complaint alleged that the facility does not provide the resident with adequate storage space for personal belongings. 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 does not ensure resident has adequate storage space for personal belongings. All staff (S1-S4) stated that all residents have the required storage space as it pertains to Title 22 regulations. Each resident has a dresser, nightstand, and a shared closet with their roommate. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff does not ensure resident has adequate storage space for personal belongings. Residents stated that they have adequate space in their room which includes a dresser, nightstand, lamp, and closet space that they share with their roommate. LPA toured the bedrooms and observed that the residents have a large room with enough space to accommodate a bed for each resident, chest of drawers, nightstand, and enough closet space that is shared by two roommates.

Based on interviews and observations, there is insufficient evidence to support the allegation that Staff does not ensure resident has adequate storage space for personal belongings. 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- Resident was not accorded assistance by staff after having fallen.

The details of the complaint alleged that the facility did not assist the resident after the resident fell in the facility. 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 Resident was not accorded assistance by staff after having fallen. All staff (S1-S4) stated that R1 did not fall in the facility because someone kicked their walker, and they do not have a record of R1 falling in the facility. They state if a resident fell, the staff is fully trained to assist the resident and would not leave the resident on the ground and certainly not ignore them. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Resident was not accorded assistance by staff after having fallen. Residents stated that the staff are responsive to their needs and are happy with the care and supervision they are receiving from the staff. They state that if they were to fall on the ground, they are confident that the staff would help them. They also stated they had no knowledge of a resident falling because someone kicked their walker.

Based on interviews, there is insufficient evidence to support the allegation that Resident was not accorded assistance by staff after having fallen. 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.

Report continued on LIC9099-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1075
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: 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 4
Control Number 31-AS-20230919142727
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
Allegation # 3- Staff does not ensure resident is accorded dignity in her personal relations ships with staff, residents.

The details of the complaint alleged that the facility does not ensure the resident is accorded dignity in her personal relationships with staff and residents; and that they are being harassed by another resident. 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 does not ensure resident is accorded dignity in her personal relations ships with staff, residents. All staff (S1-S4) stated that R1 and all residents are accorded dignity with their relationships with staff and residents. Staff stated that the R1 has a history of not getting along with other residents. Staff also stated that the resident had to change rooms on multiple occasions because R1 could not share space with other residents because R1 would complain that they were disturbing R1. They stated if R1s roommate had a visitor, R1 would complain that they were talking too much and harassing R1. Moreover, the staff stated that R1 was never happy at the facility.

LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff does not ensure resident is accorded dignity in her personal relations ships with staff, residents. Residents stated that they were happy with the care and supervision being provided to them, and that the staff does ensure they are accorded dignity in their relationships with staff and residents. The residents further stated that they have not been harassed nor have they harassed anyone.

Based on interviews, there is insufficient evidence to support the allegation that Staff does not ensure resident is accorded dignity in her personal relations ships with staff, residents. 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 # 4- Staff do not ensure resident is spoken to in an appropriate manner.

The details of the complaint alleged that the staff speaks to the resident in an inappropriate manner. In that the staff yells and speaks rudely to the resident. 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 ensure resident is spoken to in an appropriate manner. All staff (S1-S4) stated that R1 has never been spoken to disrespectfully or in an inappropriate manner. They state that they treat all the residents with dignity and respect. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not ensure resident is spoken to in an appropriate manner. Residents stated that they have never been spoken to in an inappropriate way nor have they witnessed any other resident being yelled at or intimidated by another staff or resident.

Based on interviews, there is insufficient evidence to support the allegation that Staff do not ensure resident is spoken to in an appropriate manner. 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.

Report continued on LIC9099-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1075
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: 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 4
Control Number 31-AS-20230919142727
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
Allegation # 5- Staff do not ensure medications are dispensed as prescribed to resident in care.

The details of the complaint alleged that the facility did not dispense the correct medication for the resident. 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 ensure medications are dispensed as prescribed to resident in care. All staff (S1-S4) stated that R1 always received their medication as prescribed but that the resident has a history of refusing their medication and they can’t force the resident to take it. LPA reviewed the Medication Administration Record and observed that from 08/01/23 -10/31/2023 the resident refused to take their medication repeatedly. LPA interviewed R1-R10 about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff do not ensure medications are dispensed as prescribed to resident in care. Residents stated that they always get their medication as prescribed by their physician and that the staff gives it to them at the correct times.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure medications are dispensed as prescribed to resident in care. 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 Marili Barajas, Business Office Manager, and a hard copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1075
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: 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: 4 of 4