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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603137
Report Date: 10/17/2023
Date Signed: 10/17/2023 03:02:23 PM


Document Has Been Signed on 10/17/2023 03:02 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
WOODLAND HILLS S.ASC, 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: 95DATE:
10/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Michael Stout - Welness DirectorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this facility and met with Wellness Director Michael Stout. LPA informed him the reason for the visit.

The purpose of today’s visit was to serve the Order of Immediate Exclusion from Facility for Staff #1 (S1).

The Wellness Director was served an Immediate Exclusion Order for Staff #1 (S1) who read the letter and indicated that he understood the letter. S1 was not present in the facility and had been officially terminated on January 03, 2023. Immediate exclusion certified letter was mailed to S1’s home address.

No immediate Health and Safety hazards were noted during this visit.

Exit interview held. A copy of the report was provided.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
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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