198603137-12-15-2021-28-AS-WSHO-C9WT9A-20211221133137

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 12/15/2021
Date Signed: 12/15/2021 01:00:35 PM

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
12/14/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211214102957

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: 61	DATE:	12/15/2021
		UNANNOUNCED	TIME BEGAN:	12:36 PM
MET WITH:	Darlene Romero, Administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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9

Staff stole resident's money

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegation listed above. LPA met with administrator, Darlene Romero and explained the reason for the visit.

The investigation consisted of the following: Administrator was interviewed and indicated Resident #1 (R1) was never a resident of this facility. Administrator said it's possible R1 is a resident of the sister facility across the street. Administrator provided copies of the resident roster for August, September, and October 2021. R1's name was not listed on the rosters. This facility's sister facility (Burbank Retirement Villa East) was contacted during the visit. The Administrator there confirmed R1 was a previous resident of that facility. Based on the information obtained, the allegation is unfounded.
This agency has investigated the complaint alleging staff stole resident's money. 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.
Exit interview held with Administrator. A copy of the report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

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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