198603136-3-23-2023-28-AS-TAGD-D7ENCH-20240722102044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 03/23/2023
Date Signed: 03/23/2023 02:39:50 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 28-AS-20230210122615

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: 92	DATE:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	NIrjara Atcharyan - Regional Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff failed to administer resident's medication as prescribed

Staff handled resident in a rough manner

INVESTIGATION FINDINGS:

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Licensing Progam Analysts (LPAs) Gary Tan and Abeye Duguma conducted an unnnounced subsequent complaint visit at this facility to further investigate the above allegations. LPAs met with Nirjara Atcharyan, Regional Director and explained the reason for the visit.

LPAs conducted physical plant tour at 12:00 PM, requested copy of facility documents at 12:23 PM and interviewed residents and staff between 12:30 PM to 2:15 PM. Regarding the allegation that Staff handled resident in a rough manner, it was alleged that staff withheld medication for Resident #1 (R1)'s room mate, LPA's interview with with R1 today at 12:30 PM revealed that R1 did not witness nor can recall when was medication was withheld with Resident #2 (R2). LPA's interview with R2 also revealed that there was no time that a staff withheld R2's medication. LPA's record review today at 1:00 PM revealed that R2 did not miss any medication for the last two (2) months.

(continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4364
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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 28-AS-20230210122615

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BURBANK SENIOR VILLA EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 03/23/2023

NARRATIVE

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(Continued from LIC 9099)

Regarding the allegation that Staff handled resident in a rough manner, it was alleged that a staff member pushed Resident #3 (R3) in wheelchair, LPA's interview with R3 revealed that there was no incident of any staff rough handled nor mistreated R3 at the facility. LPA's interview with Staff #1 (S1) also revealed that S1 did not push any resident nor roughly handled any resident as S1 does not directly deal with nor assist any resident, S1 just clean their room.

Based on the information gathered during this and prior visits, the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4364
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

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