198603137-3-27-2023-28-AS-NMAN-CR3VV7-20230420164552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 03/27/2023
Date Signed: 03/27/2023 04:25:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 28-AS-20230209165846

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: 97	DATE:	03/27/2023
		UNANNOUNCED	TIME BEGAN:	02:03 PM
MET WITH:	Silvia Valdez		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff is financially abusing resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegation. LPA met with the Community Ambassador, Silvia Valdez, and explained the reason for the visit.

---Staff is financially abusing resident in care.

It was alleged that facility is not issuing Resident #1’s (R1) $168.00 and month personal and incidental needs money (P&I) from Social Security. To investigate the allegation on 02/15/2023 LPA requested documents at around 2:00 PM and interviewed two (02) staff between 02:30 PM to 3:15 PM. Record review shows that R1's checking account is controlled by the power of attorney (POA). Records also show that POA gave facility authoization to debit up to $1,300.00 per month and facilty is withdrawing $1,231.77 per month to pay for R1's rent expense only.
(CONT. on LIC 9099-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: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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-20230209165846

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: BURBANK SENIOR VILLA WEST	FACILITY NUMBER: 198603137
	VISIT DATE: 03/27/2023

NARRATIVE

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During interviews with Staff #1 (S1) and Staff #2 (S2), they stated that facility is not the designated payee for Social Security income. S1 and S2 added that the POA is the payee and has never issued any additional funds for R1 to purchase things for personal needs. S1 and S2 also stated that facility has the authorization to debit up to a certain amount from R1's account but only to cover monthly rent expenses.

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

No health and safety concerns noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC9099 (FAS) - (06/04)

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