198603136-5-29-2024-31-AS-TAGD-D9UNYF-20241008105238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 05/29/2024
Date Signed: 05/29/2024 02:28:11 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.ASC, 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
10/27/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20231027164534

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:	08:53 AM
MET WITH:	Imelda Villanueva - Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff verbally abused resident

Staff financially abused a resident in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Executive Director Imelda Villanueva and explained the reason of the visit.

LPA conducted physical plant tour at 9:10 AM, requested copies of facility documents relevant to the investigation at 9:43 AM and interviewed staff and residents between 10:15 AM to 1:15 PM. Regarding the allegation that staff verbally abused resident, it was alleged that two (2) staff went to Resident #1 (R1) and cussed R1. LPA's interview with R1 on 01/17/24 revealed that there was no other person in R1's room when the alleged cussing occurs but R1 and the staff. LPA's interview with Staff #1 (S1) on 01/27/24 at 11:31 AM and Staff #2 (S2) today at 11:37 AM revealed that both staff denied cussing of verbally abusing R1. LPA's interview with ten (10) residents on 01/17/24 and additional five (5) residents between 10:15 AM to 1:15 PM today, revealed that fifteen (15) out of fifteen (15) residents or more than 15% of the current census, did not experience nor witness S1 and S2 cussing or verbally abusing any resident. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
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)

Page: 1 of 2

Control Number 31-AS-20231027164534

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BURBANK SENIOR VILLA EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 05/29/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(continued from LIC 9099)

Regarding the allegation that staff financially abused a resident in care, it was alleged that R1 loaned money to S2 but did not pay R1 back. LPA's interview with R1 on 01/17/24 revealed that R1 did not have any witness nor was able to provide any proof that R1 loaned money to S2. LPA's interview with S2 today at 11:37 AM, revealed that S2 did not ask for a loan from R1 to any resident of the facility and was aware that it was against the facility rule. The alleged incident was reported to local law enforcement on 01/15/24 but was classified by the law enforcement as false report of theft.

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

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
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)

Page: 2 of 2