198603136-5-29-2024-31-AS-NMAN-D8HSCY-20240826134619

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 05/29/2024
Date Signed: 05/29/2024 03:06:33 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
05/21/2024 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240521132318

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: 91	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Imelda Villanueva, Executive Director (E.D)		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Unused portion of resident's rent was not refunded

INVESTIGATION FINDINGS:

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At 9:50a.m Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced initial visit for the above noted allegation. LPA met with the E.D. and explained the reason for the visit.
At 10:20a.m. LPA and E.D. conducted a physical plant tour. Between 10:40a.m. to 11:30a.m. LPA interviewed E.D. and Business Office Manager (B.O.M.). LPA asked questions relevant to the nature of the complaint. At 11:45a.m. LPA obtained copies of R1’s Admission Agreement, Authorization Agreement for Pre-Authorized Payment, Resident Fund Management Service, Payer Detail Ledger, Rent Rate Increase Notice, Refund Explanation, Staff and Resident rosters relevant to the investigation. At 11:50a.m. LPA reviewed documents obtained.

1. Unused portion of resident’s rent was not refunded.

It was alleged that facility did not refund R1’s prorated amount of rent.
Continue on 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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-20240521132318

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: 05/29/2024

NARRATIVE

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Staff interviews reveal that on 04/09/2024 R1 moved out of the facility. R1 did not provide facility a verbal/written Notice of Intent to Vacate. ED indicated that on 5/14/2024 R1 was informed that a requested for refund was submitted to Savant Corporate Office. R1’s monthly rate was $1418.07 however R1 paid an additional $6.93 for the the of April towards previous balance due. R1's daily rate is $47.27. $47.27 x 21= $992.65. R1 had a previous balance of $207.81 for late payments. R1 will receive a refund of $784.84 in a form of a check. LPA interview with B.O.M. indicated that corporate office is currently processing R1’s refund request and will be mailed to R1 as soon as possible. LPA attempt several times to interview R1 via-phone and was unsuccessful. Overall, facility staff have been in communication with R1 regarding the refund. As of 04/11/2024 B.O.M terminated the withdraw of Direct Deposit from R1’s bank account. A review R1’s Admission Agreement indicates that verbal/written Notice of Intent to Vacate the facility requires a resident to provide a 30-day advance notice of intent to move or vacate the premises. Facility refund conditions will not contain an advance notice of intent to vacate, believing that would be a resident’s rights violation.

Based on interviews and documents review there is an insufficient information to support the allegation. Therefore, 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.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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