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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603137
Report Date: 03/07/2022
Date Signed: 03/07/2022 01:23:12 PM


Document Has Been Signed on 03/07/2022 01:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 SENIOR VILLA WESTFACILITY NUMBER:
198603137
ADMINISTRATOR:ZENOU, ADAMFACILITY TYPE:
740
ADDRESS:1911 GRISMER AVETELEPHONE:
(818) 295-2727
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 70DATE:
03/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Darlene Romero, Administrator TIME COMPLETED:
01:45 PM
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 Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Case management visit and met with administrator Darlene Romero. The purpose of today’s visit is to conduct a health and safety inspection and to gather information regarding the SIR/UIR (unusual incident report) dated 2/27/22, for an incident involving resident #1.

According to the incident report, the smoke detector was going off in room 202 and smoke was coming from the room. Residents were evacuated and Fire and PD were called. Staff spoke to resident #1 who currently lives in room 202 and he stated he was given a lighter by his wife. Facility staff stated that they had informed the wife not to provide the resident with a lighted prior to the incident. There were no witnesses to the incident.

During the visit LPA Baptiste interviewed administrator, reviewed resident #1 file and requested supportive documents (Resident departure form and face sheet). LPA toured resident #1 room and observed all of resident’s belongings gone and room in renovation due to fire. Resident #1 is no longer available for interview, wife moved resident out of the facility on 3/4/22.

Based on the available information, there are no citations issued per California Code of Regulations under Title 22, Division 6, at this time. Visit concluded with exit interview, copy of report given to the Administrator.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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