198603136-11-3-2023-31-AS-TAGD-D78TLH-20240716144935

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 11/03/2023
Date Signed: 11/03/2023 02:18:15 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
10/30/2023 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20231030121218

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: 99	DATE:	11/03/2023
		UNANNOUNCED	TIME BEGAN:	12:01 PM
MET WITH:	Nirjara Acharya		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are forcing resident to move rooms

INVESTIGATION FINDINGS:

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Licensing Program Analyst Gina Saucedo, Gary Tan, and Leslie Ngo-Castaneda conducted an unannounced initial visit at this facility to investigate the above allegetion. LPAs met with Nirjara Acharya and explained the reason for the visit.

LPAs conducted physical plant tour at 12:20 PM, requested copies of personnel report and resident roster at 12:40 PM. Also requested and obtained documents in regards to the investigation: admission record, physician's report and resident appraisal. LPAs interviewed resident and staff between 1:00 PM to 2:00 PM.

Allegation: Staff are forcing resident to move rooms

It was alleged that Resident #1 (R1) is in a single room currently and the staff are "forcing" R1 to move to a shared room with a roommate. (continued to LIC 9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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-20231030121218

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: 11/03/2023

NARRATIVE

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(continued from LIC 9099)

LPA's record review of the admission agreement at 1:30 PM revealed that R1 signed the Admission Agreement with the facility for a shared room. LPAs' interview with R1 at 12:50 PM, revealed that R1 was happy with current room and just did not want to move anymore. LPAs interview with staff today between 1:00 PM to 2:00 PM revealed that R1 was the one who requested to move out due to problem with room mates and vice versa. Interview with the the Regional director confirmed that the facility always notify the resident when they are moved to another room but denied voluntarily moving any resident to be moved to another room except upon the resident's request.

Based on the information gathered during this investigation, this allegation is unsubstantiated.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC9099 (FAS) - (06/04)

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