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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 11/23/2021
Date Signed: 11/23/2021 12:40:49 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2021 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211118103414
FACILITY NAME:BURBANK RETIREMENT VILLA WESTFACILITY NUMBER:
198603137
ADMINISTRATOR:ZENOU, ADAMFACILITY TYPE:
740
ADDRESS:1911 GRISMER AVETELEPHONE:
(818) 295-2727
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 61DATE:
11/23/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:S-1 and S-2TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not provide a refund to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day unannounced complaint visit to investigate the above allegation. LPA met with S-1 and discussed the purpose of today's visit. S-2/Facility Administrator arrived at approximately 12:05 P.M. During today's visit, LPA obtained Resident Roster, Staff Roster, List of Residents that have moved out of this facility for January 2021 through November 2021 and a blank Admission Agreement. LPA interviewed S-1 and S-2.

Allegation: Staff did not provide a refund to resident. The details of this allegation stated that an alleged Resident (R-1) had moved out of this facility on 10/17/21 and had previously paid the rent in full for the month of October 2021. The alleged Resident/R-1 had allegedly provided the facility a 1 week notice to vacate and was allegedly told by the Marketing Director that a refund from 10/17/21 through 10/31/21 will be issued "once corporate gets the refund together". During this investigation, LPA reviewed documents and interviewed S-1 and S-2. Staff interviews revealed that the alleged Resident (R-1) has not resided at this facility/location. Interviews conducted and and documentation review do not corroborate this allegation. **Refer to LIC 9099C for the continuation of this report**
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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 28-AS-20211118103414
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BURBANK RETIREMENT VILLA WEST
FACILITY NUMBER: 198603137
VISIT DATE: 11/23/2021
NARRATIVE
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Based on the information gathered, the allegation of "staff did not provide a refund to resident" is unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. Therefore, the complaint allegation is being dismissed.

An exit interview was conducted and a copy of this report and Appeal Rights were provided to S-2.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2