198603136-7-3-2024-31-AS-NMAN-DEVVWQ-20250318164820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:18:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/27/2024 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240627085253

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: 93	DATE:	07/03/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Executive Director, Imelda Villanueva		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff does not ensure resident's grab bars are in good repair resulting in resident sustaining falls
Staff is emotionally abusing resident

INVESTIGATION FINDINGS:

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At 10:15a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced initial visit for the above noted allegations. LPA met with the E.D. and explained the reason for the visit.

At about 10:20a.m. LPA request and received maintenance report, staff resident & rosters. At 10:45a.m. LPA and E.D. conducted a physical plant tour, interviewed randomly selected nine (9) residents including resident (R1) in their room and inspected grab bars in bathroom. At approximately 12:15p.m. LPA interviewed E.D., Maintenance Staff, Wellness Coordinator and Receptionist. LPA asked questions relevant to the nature of the complaint. At 1:50p.m. LPA reviewed documents obtained.

1) Staff does not ensure resident's grab bars are in good repair resulting in resident sustaining falls.
It was alleged that resident (R1) did not have safe grab bar and sustained a few falls in bathroom.

Continue on 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

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-20240627085253

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BURBANK SENIOR VILLA EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 07/03/2024

NARRATIVE

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Interview with resident R1 reveal that grab bars were fixed about a month ago and had no concerns. Other residents interviewed did not express any concerns regarding grab bars not in good repair. Residents indicated that their grab bars are secured, sturdy and they feel safe using them. Staff interviews reveal that all residents grab bars in bathroom are in good repair and safe. Staff (S1) indicated that R1 asked him to fix the grab bars in bathroom and S1 fixed it. R1 was happy that S1 fixed the problem. During physical plant inspection, LPA observed R1’s and other resident’s grab bars in good repair. A review of Maintenance Report dated 06/14/2024 indicates that R1 requested for grab bar in restroom to be fix and signed by S1.

Based on interviews and observation there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

2) Staff is emotionally abusing resident.

It is alleged that resident R1 would like to be called by last name.

Interview with resident R1 reveal that did not agreed with the allegation. R1 indicated that staff call them by their last name and appreciated it. R1 indicated that E.D. is nice and makes sure that staff are treating residents appropriately. Other residents also verified that staff do not emotionally abuse residents. Resident indicated that staff are respectful, helpful and have no concerns about emotionally abuse. Staff interviews reveal that residents are never emotionally abused. Staff are always calling residents by the name they wish to be called. E.D. have not received any complaints about staff emotionally abusing residents. During physical plant inspection, LPA did not observe staff emotionally abusing residents.

Based on interviews and observation there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazard is noted during this visit.

Exit interview is conducted and copy of report was provided to Executive Director.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC9099 (FAS) - (06/04)

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