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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603137
Report Date: 05/06/2023
Date Signed: 05/06/2023 02:59:19 PM


Document Has Been Signed on 05/06/2023 02:59 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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: 99DATE:
05/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Regional Director, Nirjara ArcharyallTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPAs) Antonia Alvizar and Gary Tan conducted an unannounced Required One (1) year at this facility today. LPAs met with Executive Director, Silvia Valdez, Regional Director, Nirjara Archarya and explained the reason for the visit.

A tour of the physical plant was conducted at 10:02 AM and the following was noted:

The facility consist of a two story structure that contains the following: Entrance / Lobby 1, an office for staff, and Lobby 2 / TV room areas for residents’ use, an interior courtyard, a dining room, a kitchen, a laundry room on first and second floors, storage space on first and second floors.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located in the lobby. Sign in sheet, hand sanitizer, gloves and masks are available. Some staff were observed to be wearing mask during this visit. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility.


The facility has a total of fifth-three (53) shared bedrooms. The facility is fire cleared for one hundred (100) non-ambulatory residents, ten (10) of which maybe bedridden. Approved hospice waiver for thirty (30) residents. Special Conditions on the fire clearance state the following' "Approved sliding door and window security locks for second floor dementia patient rooms". Dementia Care is listed in the plan of operation and facility accepts residents with dementia. Common areas were inspected. The activity room is located on the second floor. Dining area was observed to be neat, clean and in proper order. The facility maintains a comfortable temperature at 74°F. There are carbon monoxide detector installed in the facility. Fire extinguishers are located all throughout the facility and last inspected on 03/31/23. The facility is equipped with emergency pull alarm and sprinkler system.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BURBANK SENIOR VILLA WEST
FACILITY NUMBER: 198603137
VISIT DATE: 05/06/2023
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Laundry room on the first and second floors and was observed to be locked. Laundry detergents, cleaning agents and other toxins are stored space in the second floor locked storage room #225 inaccessible to the residents.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lit.

The bathroom was checked for cleanliness and proper operation. LPA observed that there are appropriate grab bars in the showers and toilets. The hot water temperature measure was at a range of 110.8°F to 118.9°F. There were enough clean linen available in the closets.


Medications were kept in a locked medication carts in the medication room. The medications were observed to be locked and inaccessible to residents. There are multiple complete first aid kits located in the medication room.

Facility emergency disaster plan was reviewed. Facility disaster drill was last conducted on 03/30/2023. A fire inspection by the LAFD was last performed on 02/09/2023. In addition to the physical plant inspection, residents and staff records were reviewed.

There is no body of water at the facility. Back and front yard passageways were observed to be clear from obstruction. There is a shaded area in front of the building for residents.

LPAs reviewed files of five (5) randomly selected residents. Residents’ files appear to be complete and updated. Seven (7) staff files were also reviewed, staff files appear to be complete and updated.

Exit interview conducted. A copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2023
LIC809 (FAS) - (06/04)
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