198603137-10-23-2024-31-AS-NMAN-DAHQXZ-20241029123422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 10/23/2024
Date Signed: 10/23/2024 04:38:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/01/2023 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230901160257

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: 93	DATE:	10/23/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Wellness Director, Lorena De Luna & Executive Director, Silvia Valdez		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff did not notify resident's responsible party of a change in condition
Staff did not administer resident's medications as prescribed
Staff did not assist resident with feeding
Staff did not ensure resident's hygiene needs were being met

INVESTIGATION FINDINGS:

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At 1:30PM Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to complete an investigation and deliver findings of the above noted allegations. LPA met with De Luna and explained the reason for the visit. At approximately 1:55PM Silvia Valdez joined us.

During initial visit on 09/08/2023 at 12:05p.m. LPA Alvizar-Ettima requested copies of the facility resident and staff roster. LPA and the Administrator conducted a physical plant walk-through, at approximately 12:20PM. LPA did not observe any immediate health and safety issues during the inspection. At 12:35PM LPA requested and obtained resident R1 Identification and Emergency Information, Physician’s Report, Physician’s Order, Preplacement Appraisal Information, Individual Service Plan, and Medication Administration Records (MARs).
Prior to this visit on 10/22/2024 LPA Antonia Alvizar-Ettima reviewed the available records, including incident
Continue on LIC 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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 31-AS-20230901160257

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/23/2024

NARRATIVE

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reports and other documents obtained from the facility.

During this visit at 1:45PM De Luna and LPA conducted a physical plan tour. Between 2:00PM – 3:30PM LPA conducted interviews with facility staff and nine (09) out of ninety-three (93) residents. LPA asked questions relevant to the nature of the complaint. At the time of investigation, R1 was no longer at the facility.

1.) Staff did not notify resident's responsible party of a change in condition.
It was alleged that R1’s health declined, and staff never told R1’s responsible party about changes in R1’s overall health condition. Interview of facility staff revealed that staff always monitor resident's health conditions and notify resident’s responsible party if changes were noted. A review of incident report reveal that on July 31, 2023, while R1 was at an overnight stay with family, it was noted that R1 had a change of mental and physical condition. Residents interview indicated that staff always call their responsible party when they are sick and go to the hospital.

Based on interviews and records review there is not sufficient information to support this allegation. Thus, this allegation is deemed to be UNSUBSTANTIATED at this time.

2.) Staff did not administer resident's medications as prescribed

It was alleged that Resident #1(R1) was not given medication as prescribed by physician.

Staff interviews reveal that medications are always dispensed to residents as per physician order and prescription. Staff indicated that R1 sometimes refused to take medications. A review of incident reports involving R1, revealed that that at times R1 was getting agitated and refused to eat, drink, and take medication. The report verified the information received from facility staff. A review of R1’s Medication Administration Record supported the information received from staff. Residents interview revealed that staff do administer medications as prescribed and on time.

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

Continue on LIC 9099c

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230901160257

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/23/2024

NARRATIVE

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3.) Staff did not assist resident with feeding

It was alleged that R1 needed feeding assistance and staff did not provide it. Staff interviews reveal that R1 did not need feeding assistance. Staff indicated that R1 was able to self-feed. A review of R1’s Physician Report, capacity for self-care record verified the information received from facility staff. Residents indicated that staff do assist and supervise resident during meal times.

Based on interviews and record review, there is insufficient information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.

4.) Staff did not ensure resident's hygiene needs were being met

It was alleged that R1 needed toileting & bathing assistance and staff did not provide it. Staff interviews reveal that R1 was capable of self-care and did not need hygiene assistance. However, R1 needed bathing supervision but was refusing the assistance. Physician Report, capacity for self-care record verified the information from facility staff. Facility documents indicated that R1 was receiving bathing assistance on a weekly basis. However, sometimes R1 would refuse staff assistance. Residents interview revealed that staff are always assisting residents and have not seen residents with hygiene needs not being met.

Based on the interviews, information obtains and record review, this allegation is deemed unsubstantiated at this time.

No immediate health and safety issues were noted.

Exit interview was conducted and copy of was provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC9099 (FAS) - (06/04)

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