198603137-11-19-2021-28-AS-LHIS-C9NP6M-20211213100231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 11/19/2021
Date Signed: 11/19/2021 11:56:30 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211116152458

FACILITY NAME:	BURBANK RETIREMENT 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: 59	DATE:	11/19/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Mae Nieva, Med Tech		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident missed scheduled optometrist appointments while in care.
Staff did not address a resident's change in medical condition.
Staff do not properly maintain a resident's room.
Staff speak inappropriately towards a resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced complaint investigation regarding the allegations above. LPA met with Mae Nieva and explained the purpose of the visit. The Administrator was not present during the visit.

On today's visit, LPA interviewed the Staff and obtained the resident and staff rosters.

Based on interview and document reviewed, Resident #1 (R1) does not reside at this facility. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted. A copy of this report along with appeal rights were given to Staff.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021

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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