198603137-3-9-2024-31-AS-AAEA-D3838W-20240309170213

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603137
Report Date: 03/09/2024
Date Signed: 03/09/2024 05:02:20 PM

Document Has Been Signed on 03/09/2024 05:02 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

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: 91	DATE:	03/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:			TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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 Acharya and explained the reason for the visit. A tour of the physical plant was conducted at 10:00 AM and the following was noted: The facility consists 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. The screening area is in the lobby. Sign in sheet, hand sanitizer, gloves and masks are available. Some staff were observed to be wearing masks 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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BURBANK SENIOR VILLA WEST	FACILITY NUMBER: 198603137
	VISIT DATE: 03/09/2024

NARRATIVE

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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 105.9°F to 111.3°F. There was enough clean linen available in the closets.

Medications were kept in 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 02/27/2024. A fire inspection by the LAFD was last performed on 05/05/2023. 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 six (6) randomly selected residents. Residents’ files appear to be complete and updated. Six (6) 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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024

LIC809 (FAS) - (06/04)

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