198603137-8-8-2023-28-AS-LHIS-CUPMND-20230814094519

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 08/08/2023
Date Signed: 08/08/2023 12:57:40 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
05/02/2022 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220502130402

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: 98	DATE:	08/08/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Silvia Valdez		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility staff did not provide adequate care to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted a subsequent visit in response to the above allegation. On today's visit, LPA met Executive Director, Silvia Valdez, who assisted with the visit.

Regarding the allegation: Facility staff did not provide adequate care to resident #1. The investigation consisted of interviews with Executive Director, Staff #1 - Staff #3, Resident #1, and review of resident #1's file. The investigation revealed that on 4/28/2022, facility staff called 911 due to resident #1 being unresponsive. Resident #1 was admitted to hospital, was discharged, and returned to the facility on 5/1/22. Executive Director and staff interviewed stated that the facility is providing adequate care to resident #1. They stated that the incident occurred due to resident #1's blood glucose level being low. Facility staff indicated that resident #1's glucose was being checked daily by home health. LPA observed resident #1 blood sugar records for May 2022, and observed that it was being checked daily. During initial visit on 5/11/22, staff indicated that resident #1 was receiving oral medications, not insulin, and was compliant with medications.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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-20220502130402

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: 08/08/2023

NARRATIVE

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Executive Director stated that resident #1's blood sugar is still being monitored on a daily basis, by the facility LVN or by the Home health nurse. Executive Director stated that Resident #1 is doing well, and has not returned to the hospital for having low blood glucose levels.

Staff interviewed stated that snacks are provided to residents to ensure that their glucose levels remain stable. Resident #1 was unable to answer questions regarding the allegation, due to cognitive impairment.

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

Exit interview was conducted, and a copy of this report was provided to Ms. Valdez.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

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