198603137-2-25-2022-28-AS-NMAN-CBZ3JS-20220225171801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603137
Report Date: 02/25/2022
Date Signed: 02/25/2022 05:18:15 PM

Document Has Been Signed on 02/25/2022 05:18 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

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: 68	DATE:	02/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Licensee Adam Zenou and Co-Licensee Mochi Bercovich		TIME COMPLETED:	05:20 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 (LPA) Nune Margaryan conducted an annual required visit. LPA met with Licensee Adam Zenou and Co-Licensee Mochi Bercovich who assisted with the visit. The purpose of the visit was explained. The facility cares for elderly residents with dementia and approved for 100 Non-Ambulatory residents; of which ten (10) may be bedridden. Facility is approved to retain/accept thirty (30) hospice residents. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed residents and staff files. Facility has submitted a mitigation plan and the plan has been approved. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is located in a residential area and consist of a two story structure that contains the following: Entrance / Lobby 1, an office for staff, and Lobby 2 / TV room areas for resident use, an interior courtyard, a dining room, a kitchen, a laundry room on first and second floors, storage space on first and second floors. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located in the lobby. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit. LPA toured randomly selected residents rooms. All bedrooms were furnished with required furniture. The bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. The hot water temperature was tested throughout the facility and measured within Title 22 Regulations guidelines. Continue 809C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BURBANK SENIOR VILLA WEST	FACILITY NUMBER: 198603137
	VISIT DATE: 02/25/2022

NARRATIVE

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The kitchen was toured. All appliances were clean and operating properly. There was a sufficient amount of perishable and non-perishable food. Smoke alarms and carbon monoxide alarms were operational, fire extinguishers on first and second floor observed to be fully charged.
LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations.
LPA reviewed 7 residents and 5 staff records. Residents' records were found to be complete and current. Staff files were reviewed, and documentation noted that facility staff maintain a criminal record clearance and associated to the facility. LPA randomly chose some residents' medications to review. Medications are documented properly and stored appropriately.

Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to the Licensee

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

LIC809 (FAS) - (06/04)

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