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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603137
Report Date: 01/04/2023
Date Signed: 01/04/2023 12:48:56 PM


Document Has Been Signed on 01/04/2023 12:48 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,
, CA



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: 98DATE:
01/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Silvia Valdez - Community AmbassadorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this facility to investigate the self reported incident occurred on 12/28/22 wherein Staff #1 (S1) was caught having sexual intercourse with Resident #1 (R1). LPA met with Community Ambassador Silvia Valdez and explained the reason for the visit.

LPA conducted physical plant tour at 9:45 AM, requested copies of facility documents relevant to the investigation at 10:15 AM and interviewed staff between 10:30 AM to 12:30 PM. LPA's interview with the Community Ambassador at 10:30 AM revealed that once they learned about the incident, R1 was not allowed to work the following day (12/29/22) or was suspended pending investigation. Further, R1 was eventually terminated on effective 01/03/2023 and no longer allowed entry at this and sister facility across the street. LPA's record review today at 12:30 PM also revealed that Local Law Enforcement was called and investigated the incident on 12/29/22.

There is no health and safety issue noted during this visit.

Exit interview conducted. Copy of this report issued.



SUPERVISOR'S NAME: Alex EstradaTELEPHONE: (818) 596-4364
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
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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