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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 05/14/2024
Date Signed: 05/14/2024 11:16:52 AM

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
04/18/2023 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 31-AS-20230418144741
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:
05/14/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Executive Director Imelda VillanuevaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not prevent a resident from causing harm to another resident while in care.
Visitor vandalized a resident's room while in care.
INVESTIGATION FINDINGS:
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On 05/14/24 at 9:35 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 04/21/23 LPA Antonia Alvizar interviewed R1. On 05/14/24 LPA Villegas obtained copies of the following: staff and resident roster(s) and facility rules, LPA also obtained copies of the following for R1; Facesheet, admission agreement, physicians report, needs and service plan, physician’s orders MAR for April, May, and June 2023, and the following documents for R2; facesheet, admission agreement, physicians report, pre-appraisal, physician’s orders MAR for March and April 2023, resident’s departure form, medication release form for R2, documented room changes for R2. On 05/14/24 LPA Villegas interviewed residents #3-10 (R3-R10), staff #1-4 (S1-S4), and Executive Director (ED).


Allegation: Staff did not prevent a resident from causing harm to another resident while in care
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1075
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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-20230418144741
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: 05/14/2024
NARRATIVE
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The investigation revealed the following:

Allegations: Staff did not prevent a resident from causing harm to another resident while in care.

It is being alleged that R2 would often curse at R1 and yell threats. On 05/14/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above. Per ED, R1 and R2 came to ED on 04/12/24 to report verbal feud, ED offered a room change which would have been R2’s 4th room change however room change was not done as R2 was taken to LADMC for psychological evaluation on 04/13/23 and on 04/14/23 R2 was discharged from the facility by responsible party. 05/14/24 LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported there are de-escalation procedures in place to ensure all residents are happy and comfortable. Per 4 of 4 staff, room changes take place when roommates are not getting along. On 04/21/23 LPA Alvizar interviewed R1 regarding the allegation above, per R1 staff did not prevent R2’s relative from yelling and cursing at R1. R1 denied R2 causing harm to R1. LPA was unable to interview R2 since R2 is no longer a resident at the facility and R2 whereabouts are unknown at this time. On 05/14/24 LPA interviewed R3-R10 regarding the allegation above, 7 of 7 residents interviewed denied the allegation above and reported feeling safe at the facility. LPA unable to interview R2 are no longer receiving care at Burbank Senior Villa East. On 05/14/23 LPA conducted records review and observed document listing all dates R2 had room changes due to not getting along with roommates. Based on interviews conducted and records reviewed their were no witnesses or documentation to corroborate that R2 yelled / cursed or causes harm to R1, therefore the allegation is unsubstantiated.

Allegation: Visitor vandalized a resident's room while in care

It is being alleged that on 04/14/23 R1’s belongings were vandalized by R2’s relative. It is alleged during the incident R1 property was damaged. On 05/14/24 LPA interviewed ED regarding the allegation above, ED confirmed that an incident did occur on 04/14/23 between R1 and R2’s relative as R2 was in the process of being moved out of the On 05/14/24 LPA interviewed S1-S4 regarding the allegation above, 1 of 4 staff interviewed reported being present when the incident occurred and reports assisting ED with de-escalating the incident. 1 of 4 staff continued to report that ED called the police right away and assisted with removing R2 and R2’s relative from the bedroom to ensure safety. 3 of 4 staff interviewed reported not having any details on the incident. On 04/21/23 LPA Alvizar interviewed R1 regarding the allegation above, per R1 R2’s relative made it into the bedroom and began throwing belongings out of the closet resulting in a wooden

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1075
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20230418144741
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: 05/14/2024
NARRATIVE
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divider to be cracked. On 05/14/24 LPA interviewed R3-R10 regarding the allegation above, 7 of 7 residents interviewed denied the allegation above and reported that their belongings have not been vandalized while living at the facility. LPA unable to interview R2 as R2 is no longer receiving care at Burbank Senior Villa East. On 05/14/24 at 10 am LPA conducted a review of the facility and there is no documentation of any similar incidents occurring at the facility. On 05/14/24, LPA reviewed R1 Property Inventory sheet and did not observe a room divider documented. LPA reviewed the incident report for the occurrence, and it does not indicate any of R1 belongings were vandalized. Based on interviews conducted and records review, on 04/14/23 an incident occurred between R1 and R2’s relative, records detail that during the incident a room divider was cracked but no other damage was noted. Interviews with witnesses conducted did not corroborate R2 relative cracking the room divider. There is no photographic evidence or surveillance footage to support the allegation. Based on interviews and records reviewed there is not enough evidence to support the allegation therefore the allegation is unsubstantiated..

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 is unsubstantiated.

Exit interview conducted with Executive Director Imelda Villanueva, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1075
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: 424-544-1075
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3