198603136-10-23-2024-31-AS-NMAN-DAH9RT-20241028233628

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 10/23/2024
Date Signed: 10/23/2024 02:08:02 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, 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
07/02/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240702155732

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:	10/23/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Executive Director, Imelda Villanueva		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff did not ensure residents personal property was safe guarded
Facility bathroom is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above allegation. LPA met with Imelda Villanueva and explained the reason for the visit.

---Staff did not ensure residents personal property was safe guarded

It was alleged that Resident #2 (R2) stole items like crackers and patrician packets from Resident #1 (R1). To investigate the allegation, on 10/09/2024 LPA requested documents at around 11:00am, interviewed four (04) staff from 12:00pm to 1:30pm and interviewed nine (09) residents from 1:30pm to 3:30pm. A review of Resident #1’s (R1) record review indicates that file has an appendix of resident personal property and valuables document which clearly states that R1 refused inventory and signed it. LPA also reviewed the departments records and did not find incident reports regarding theft of R1’s or any other residents’ belongings going missing around the period in question.
(CONT. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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-20240702155732

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BURBANK SENIOR VILLA EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 10/23/2024

NARRATIVE

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During interviews with staff, all staff stated they are not aware of R2 stealing anything from R1. During interviews with resident, all residents stated they have not experienced any issues with theft and feel that their belongings are safe guarded. LPA was unable to interview R1.

Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Facility bathroom is in disrepair

It was alleged that the bathroom in the common room has been out of order for four (04) days. To investigate the allegation, on 10/09/2024 LPA requested documents and conducted a physical plant tour at around 11:00am, interviewed four (04) staff from 12:00pm to 1:30pm and interviewed nine (09) residents from 1:30pm to 3:30pm. During the physical plant tour, LPA observed common bathroom in working order. LPA also selected three (03) additional bathrooms at random and observed everything to be in working order. A review of the maintenance work order shows that there were no issues with the common bathroom during the time in question. During interviews with staff, all staff stated they are unaware of any common bathrooms being in disrepair. During interviews with resident, all residents stated they are not aware of any common bathrooms being out of order.

Based on observations, record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC9099 (FAS) - (06/04)

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