198603137-2-24-2023-28-AS-MVAO-CPHS6B-20230301123540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 09/16/2022
Date Signed: 02/24/2023 10:00:03 AM

Unsubstantiated

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
07/05/2022 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220705112304

FACILITY NAME:	BURBANK SENIOR VILLA WEST		FACILITY NUMBER:	198603137
ADMINISTRATOR:	ZENOU, ADAM		FACILITY TYPE:	740
ADDRESS:	1911 GRISMER AVE		TELEPHONE:	(818) 295-2727
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	100	CENSUS:	DATE:	09/16/2022
		UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Silvia Valdez Community Ambassador		TIME COMPLETED:	04:16 PM

ALLEGATION(S):

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Staff are not addressing a resident's diabetic needs while in care
Staff are retaining a resident who needs a higher level of care
Staff did not ensure a resident attended schedule dialysis appointment

INVESTIGATION FINDINGS:

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**** This amended report supersedes report dated 09/16/2022. It was created to add additional information to support 1st allegation finding that was gathered from subsequent interview with facility staff Silvia Valdez. The additional revision did not change any other aspects of the report and all aspects including the findings remain the same.***

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced subsequent complaint visit in response to the above allegations. LPA met with Silvia Valdez Community Ambassador, who assisted with today's visit. Initial visit was on 07/07/2022

During initial visit visit, LPA interviewed Administrator S5 and Staff #1-4, LPA requested and obtained copies of specific documents from Resident #1's file, R1 D/C order, R1 functional capability assessment, Preplacement Appraisal Information, , SIR dated 6/27/22, 6/28/2022 6/29/22, R1 Physician’s report for residential care facilities for the elderly (RCFE) R1 Admission record, face sheet and Physician’s orders. R1 order summary report and LPA also interviewed R2-R6

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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 28-AS-20220705112304

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 SENIOR VILLA WEST	FACILITY NUMBER: 198603137
	VISIT DATE: 09/16/2022

NARRATIVE

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During subsequent visit, LPA obtained copies of text messages between S2 and W2 interviewed R7-R11 and conducted 2nd interview with Silvia Valdez Community Ambassador
Regarding Allegation: Staff are not addressing a resident's diabetic needs while in care. It is alleged that resident’s diabetic needs where not taken care of. 5/5 staff denied allegations and stated they provide care based on doctor’s orders. 10/11 residents stated they get good care at facility and are happy to be at facility S2 stated that title 22 prohibits Glucose testing or any king of injection by facility staff. R1 was provided diabetic medication in pill form. S2 stated R1 did not have home health order because R1 only had Medi-Cal and it does not cover Home Health. R1 was not on insulin when she arrived at facility. S2 did follow up with R1 MD and followed recommendations. R1 was provided medication and special diet assistance during the short time at facility. From information gather from the staff, file review and interviews with staff there is not enought evidence to proof the above allegation.

Therefore, the allegation is Unsubstantiated.

Regarding Allegation: Staff are retaining a resident who needs higher level of care. It is alleged that facility is retaining a resident that requires higher level of care. 2/5 staff stated they believed that R1 needed higher level of care. Resident arrived at facility on June 24^th, 2022 and on June 29^th, 2022 she was sent to hospital and never returned to facility. She was placed in skill nursing facility due to needing a higher level of care. Facility addressed residents needs and made sure she would get the care she needed at skilled nursing facility. There is not enough evidence to proof that facility was retaining resident since she was only “officially” at facility 6 days. Therefore, the allegation is Unsubstantiated.

Regarding Allegation: Staff did not ensure resident attended schedule dialysis appointment. It is alleged that facility failed to ensure resident make her dialysis appointment. According to staff #2 Resident arrived on June 24^th, 2022 and had made her dialysis appointment that day. Her next scheduled dialysis appointment was on June 27^th, 2022 and it was rescheduled by the transportation company to June 28^th, 2022 at 8:30am. However, on June 28^th 2022 at 5:00AM resident was transported to hospital due being unresponsive and did not make that appointment at 8:00AM. Dialysis appointment was rescheduled for the 29^th of June 2022 at 8:30am. According to S2 transportation called and rescheduled for 2:00pm. Transportation did not show up on 29^th 2002 AT 2:00PM. Staff attempted to arrange for wheelchair transportation via UBER to take resident to her dialysis appointment. S2 stated contacted ambulance service but it was 4 hour wait. According to staff, there was no UBER available that had wheelchair transportation. At around 5pm on the 29^th of June after calling 911 client was sent to hospital and never returned to facility. Therefore, the allegation is Unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

Exit interview was conducted with Silvia Valdez, Community Ambassador and copies were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC9099 (FAS) - (06/04)

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