Inspection Reports for
Savant of Burbank East

The visit was complaint-related under investigation control #31-AS-20241220150010. The deficiency observed was related to the complaint but was not alleged.

The licensee failed to properly reassess and conduct ongoing reappraisals or update the needs and service plan for a change in condition for resident #1 in a timely manner. A Type B deficiency was issued for not updating resident #2's appraisal needs and services upon observing a change in condition, posing a potential health, safety, or personal rights risk.

The complaint was substantiated. Allegations included staff yelling at a resident and failure to maintain a comfortable environment. Interviews, observations, and record reviews confirmed these issues.

The investigation substantiated that staff yelled at a resident and that the facility did not maintain a comfortable environment for residents due to a resident's screaming. Deficiencies related to personal rights violations were cited.

The complaint was substantiated. It involved insufficient supervision contributing to resident #1 sustaining multiple falls and injuries. The facility was aware of the resident's need for higher care but retained the resident and failed to provide adequate safety measures. An immediate civil penalty of $500 was assessed.

The investigation substantiated the allegation that the facility failed to provide adequate supervision to resident #1, resulting in multiple falls and serious injuries. The facility retained the resident despite knowing a higher level of care was needed and did not implement sufficient safety measures until relocation.

The complaint alleged staff forced a resident to cut their hair. Interviews with the executive director, six staff members, and nine residents indicated no resident gets a haircut against their will. However, the resident's hair was cut from waist length to shoulder length with consent due to tangles, but staff did not obtain family permission or update the service plan. The allegation was substantiated.

The allegation was substantiated based on interviews with staff, residents, and review of records. Staff cut the resident's hair without family permission and failed to update the resident's service plan or notify the Power of Attorney, posing a risk to resident rights and safety.

The complaint investigation was substantiated for the allegation of questionable death due to rooftop access. Other allegations including financial abuse, failure to prevent harm by another resident, and failure to provide a safe environment were unsubstantiated.

The allegation of questionable death was substantiated due to the facility's failure to keep the rooftop locked, which allowed the resident access resulting in death. Other allegations regarding financial abuse, failure to prevent harm by another resident, and failure to provide a safe environment were unsubstantiated based on interviews, record reviews, and evidence.

Complaint substantiated. Resident #1 sustained pressure injuries while in care, with evidence showing inadequate care and worsening of pressure ulcers. Civil penalties were assessed.

The investigation substantiated that Resident #1 sustained worsening stage III and IV pressure ulcers due to inadequate care at the facility. The facility retained a resident with advanced dermal ulcers, which is prohibited.

The complaint investigation was substantiated. Allegations included resident hospitalization due to staff neglect, development of pressure injuries, and inadequate food and liquid intake. The resident was found unresponsive and hospitalized on 2021-01-03 after being observed with deteriorating condition for up to three weeks. Facility staff did not send the resident to hospital despite changes in condition and did not document or communicate these changes to the primary care physician. The resident was diagnosed with multiple serious conditions including septic shock, dehydration, malnutrition, and stage 2 pressure injuries.

The investigation substantiated that a resident was hospitalized due to staff neglect, developed multiple pressure injuries while in care, and did not receive adequate food and liquids. The facility failed to observe and document changes in the resident's condition and did not ensure timely medical attention.

The complaint investigation was substantiated for allegations that a resident missed scheduled optometrist appointments due to lack of transportation and that staff did not address a resident's change in medical condition related to vision. The allegations that staff did not properly maintain a resident's room and that staff spoke inappropriately towards a resident were unsubstantiated.

The investigation substantiated that the facility failed to provide transportation for a resident's optometrist appointment and failed to update the resident's medical condition related to vision changes. The allegations regarding improper maintenance of a resident's room and inappropriate staff speech were found to be unsubstantiated due to insufficient evidence.

The complaint alleged that a resident was isolated in a room infested with bed bugs and that staff did not clean the room after being made aware of the problem. The resident was quarantined due to possible shingles, not bed bugs. Pest control and staff confirmed bed bug presence. Two out of ten residents reported bed bugs in their rooms. The allegation was substantiated.

The investigation found that the facility had bed bugs between June 2020 and October 2020, confirmed by pest control records, staff and resident interviews, and physical inspection. The allegation was substantiated and a deficiency was cited for failure to maintain a clean, safe, and sanitary environment.

The complaint investigation was substantiated for the allegations that a resident was stuck in the elevator and the elevator phone was not functioning. The allegation that staff did not report an unusual incident to CCL was unsubstantiated.

The investigation substantiated that a resident was stuck in the elevator and the elevator phone was not functioning, though the elevator itself operated properly. Another allegation that staff did not report an unusual incident to the Community Care Licensing was unsubstantiated.

The complaint investigation was triggered by allegations received on 12/26/2019 regarding staff not providing timely medication, inaccurate medication logs, inadequate food service, failure to meet dietary needs, failure to keep the facility clean, and failure to respond to call buttons in a timely manner. The allegation regarding call button response was substantiated; others were unsubstantiated.

The investigation found most allegations unsubstantiated due to lack of preponderance of evidence, except for the allegation that staff did not respond to residents' call buttons in a timely manner, which was substantiated. The facility was found to have sufficient food service, accurate medication logs, and was clean and in good repair after renovations.

The complaint investigation was initiated based on allegations received on 2021-05-25. The allegations included refusal to provide medical records, lack of privacy during diaper changes, and staff yelling at residents. The refusal to provide medical records and privacy allegations were unsubstantiated, while the staff yelling allegation was substantiated.

The investigation found the allegations of refusal to provide medical records and lack of privacy during diaper changes to be unsubstantiated due to insufficient evidence. However, the allegation that staff yelled at residents was substantiated based on interviews and observations, with Staff #1 confirmed to have yelled at residents, posing a risk to their health, safety, and personal rights.

The complaint investigation was substantiated for the allegation of bed bugs and pest infestation, with evidence from interviews and pest control records. The allegation of staff not treating residents with dignity and respect was unsubstantiated due to lack of evidence.

The investigation substantiated the allegation of bed bugs and german roaches in some resident rooms, with pest control services only treating select rooms. The allegation regarding staff not treating residents with dignity and respect was found to be unsubstantiated based on interviews and records.