198603136-11-12-2024-31-AS-EMIR-DDNVGP-20250207152549

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 11/12/2024
Date Signed: 11/12/2024 02:35:22 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
11/04/2024 and conducted by Evaluator Lorena Casillas

COMPLAINT CONTROL NUMBER: 31-AS-20241104163555

FACILITY NAME:	SAVANT OF BURBANK 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:	11/12/2024
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Imelda Villanueva		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff did not properly supervise resident, resulting in resident falling.

INVESTIGATION FINDINGS:

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On 11/12/2024 at 10:40 am Licensing Program Analyst (LPA), Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegations. LPA met with Administrator Imelda Villanueva and explained the reason for the visit.

At 11:30 AM LPA Casillas conducted a physical plant tour. During the investigation, interviews and record reviews were made from 11:00 am to 2:30 pm. LPA requested resident roster, Liability Insurance, and LIC 500. LPA requested copies of pertinent information relevant to the investigation including but not limited to resident records, and any other documents pertaining to the investigation.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

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-20241104163555

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: SAVANT OF BURBANK EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 11/12/2024

NARRATIVE

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Allegation: Staff did not properly supervise resident, resulting in resident falling.

It is alleged that staff did not properly supervise resident, resulting in resident falling. Regarding this allegation, it is reported that Resident #1 (R1) sustained injuries from a fall while ambulating with a walker when R1 felt dizzy and fell. It is further reported that R1 was left on the floor while a chair was secured. Interview with Administrator denied the allegation and revealed that R1 has not been left unsupervised, and that there has been no fall reported by staff or residents. It was also revealed based on record review that R1 is capable of walking without assistance and has no reported falls or injuries. Interview with ten (10) residents revealed that they are independent and have no issues with falls or being left unsupervised. Interview with five (05) staff revealed that no residents have reported a fall within the last few weeks, nor have staff witnessed any residents falling. Interview with R2 revealed that R1 may have made up that R1 fell as no one witnessed the alleged fall. Therefore, based on observations, record reviews and interviews this allegation is deemed unsubstantiated.

No citation issued. Exit interview conducted. Copy of report given to Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024

LIC9099 (FAS) - (06/04)

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