198603136-1-23-2025-31-AS-NMAN-DDS2CP-20250210161703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 01/23/2025
Date Signed: 01/23/2025 01:46:55 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
09/27/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240927130858

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:	01/23/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Imelda Villanueva		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Neglect in care and supervision contributed to residents death.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Imelda Villanueva and explained the reason for the visit.

--- Neglect in care and supervision contributed to resident’s death.

It was alleged that resident’s roommate tried to assist resident while choking but was unsuccessful, that there was only one (01) caregiver in the facility on the 1st floor and staff responded to the call for help ten (10) hours after expiration. To investigate the allegation, on 12/04/2024, LPA requested pertinent documents at around 11:00a.m., interviewed five (05) staff from 11:30a.m. to 1:00p.m. and nine (09) residents from 1:00p.m. to 3:30p.m.

(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: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

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-20240927130858

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: SAVANT OF BURBANK EAST	FACILITY NUMBER: 198603136
	VISIT DATE: 01/23/2025

NARRATIVE

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A review of hospice records revealed Resident #2 (R2) was receiving hospice services for a terminal illness and last visit by hospice agency professional was 08/30/2024. Death Report states that on 09/02/2024 resident was found unresponsive at 4:15p.m., emergency arrived at 4:30p.m., paramedics pronounced resident dead at 5:16p.m. and coroners picked up resident at 10:20p.m. Visitor’s Log does not show R2 had a visitor on 09/02/2024. A review of staff schedule for 09/02/2024 shows facility had three (03) caregivers and one (01) MedTech for both morning and afternoon shifts. A review of Physician’s Report and Needs and Services Plan does not indicate R2 had swallowing difficulties.

During interviews with staff, all staff stated resident was found unresponsive by MedTech Staff #1 (S1) as they were making medication rounds. S1 checked vitals, requested emergency services, and attempted to resuscitate R2. Staff #2 (S2) added paramedics and police arrived, then shortly after, the coroners.

During interviews with residents, Resident #1 (R1) stated they did not witness anything, does not know the name of the alleged neglected resident, and only heard from others what happened. Resident #3 (R3) stated they did not find their roommate R2 choking or try to assist R2 while choking. R3 stated they found R2 deceased and that it looked like R2 was sleeping. R3 called out for help and staff came within thirty (30) minutes, however, R3 also stated R2’s doctor was in the room before staff arrived but did not attempt to resuscitate. R3 contrarily added that it was the doctor who called out for help. All other residents stated they are unaware of anyone choking to death or staff failing to aid anyone choking.

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

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC9099 (FAS) - (06/04)

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