Inspection Reports for Savant of Burbank East
1900 Grismer Ave, Burbank, CA 91504, United States, CA, 91504
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and the majority of complaint investigations were unsubstantiated, indicating generally consistent compliance with regulations. However, there have been some substantiated deficiencies primarily related to resident care, supervision, and maintaining a safe environment. The most serious issues include a resident’s death in December 2023 due to the rooftop being left unlocked, multiple substantiated cases of inadequate care leading to pressure injuries and neglect between mid-2023 and 2024, and failures to update resident service plans or provide timely supervision. The most recent report from October 15, 2025, identified one deficiency involving a failure to update a resident’s service plan but did not note any immediate jeopardy or enforcement actions. Overall, the facility shows some improvement over time with fewer severe deficiencies in recent reports, though isolated issues with care planning and supervision remain.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 1
Oct 15, 2025
Visit Reason
The case management visit was conducted to address a deficiency observed during the course of investigation control #31-AS-20241220150010, related to a complaint.
Findings
The licensee failed to properly reassess and conduct ongoing reappraisals or update the needs and service plan for a resident in a timely manner, which poses a potential health, safety, or personal rights risk to persons in care.
Complaint Details
The visit was triggered by a complaint investigation under control #31-AS-20241220150010. The deficiency observed was related to the complaint but was not alleged. The deficiency was substantiated and a deficiency notice was issued with appeal rights explained.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to update resident #2's appraisal needs and services upon observing change in condition as required by Section 87463-Reappraisals. | Type B |
Report Facts
Capacity: 100
Census: 92
Plan of Correction Due Date: Oct 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Huma Rahimi | Licensing Program Analyst | Conducted the case management visit and signed the report |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during the inspection |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 100
Deficiencies: 0
Jul 28, 2025
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including staff stealing resident’s money, cutting resident’s hair without consent, neglecting resident hygiene, and untimely assistance to residents.
Findings
The investigation found all allegations to be unsubstantiated after interviews with residents and staff, consistent with previous complaint findings from 03/19/2025.
Complaint Details
The complaint investigation was unannounced and involved interviews with 10 residents and staff including the Administrator, Caregiver, Business Office Manager, Wellness Director, and Wellness Coordinator. All allegations remain unsubstantiated.
Report Facts
Residents interviewed: 10
Facility census: 97
Facility capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nadia Shahbazian | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Conducted the complaint investigation |
| Imelda Villanueva | Administrator | Met with investigators during the complaint visit |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 100
Deficiencies: 1
Apr 9, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that insufficient supervision contributed to residents sustaining injuries.
Findings
The investigation substantiated that the facility failed to provide proper supervision for 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 adequate safety measures during the interim.
Complaint Details
The complaint was substantiated. It alleged insufficient supervision contributed to residents sustaining injuries, specifically resident #1 who had multiple falls and was on the floor for hours on at least one occasion. The facility failed to meet the resident's needs and did not provide adequate safety measures until relocation to a skilled nursing facility was arranged.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate care and supervision as required by CCR 87464(f)(1), resulting in resident #1 sustaining serious injuries from multiple falls. | Type A |
Report Facts
Civil penalty amount: 500
Number of falls: 5
Capacity: 100
Census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Imelda Villanueva | Executive Director | Met during the investigation and provided justification for retaining resident #1. |
| Nirjara Acharya | Vice President of Operations | Participated via speaker phone during the exit interview. |
| Lisa Pham | Regional Director | Participated via speaker phone during the exit interview. |
| Evelin Rios | Licensing Program Analyst | Conducted the complaint investigation and signed the report. |
| Jose Santana | Investigator | Assigned to the complaint investigation branch and conducted interviews. |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 100
Deficiencies: 0
Mar 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations received on 2024-06-19 regarding facility conditions, staff response, resident care, and treatment.
Findings
After physical plant tours, staff and resident interviews, and record reviews, none of the allegations were substantiated. Observations confirmed the facility was in good repair, staff responded to call buttons within reasonable time, residents received medical care assistance, personal care supplies were adequate, rooms were clean, food was available, and staff treated residents with dignity and respect.
Complaint Details
The complaint investigation involved allegations including poor facility repair, untimely staff response to call buttons, lack of assistance with medical care, inadequate personal care supplies, insufficient room cleaning, denial of food, and inappropriate staff communication. All allegations were found to be unsubstantiated based on observations, interviews, and record reviews.
Report Facts
Number of staff interviewed: 3
Number of residents interviewed: 9
Average hot water temperature: 112.6
Average staff response time to call button (minutes): 6
Licensed capacity: 100
Census: 93
Perishable food supply duration (days): 2
Non-perishable food supply duration (days): 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Betty Jerez | Facility representative met during the investigation | |
| Staff #1 | Staff member interviewed regarding assistance with medical care and food availability |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 0
Mar 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-05-24 regarding insufficient living space, unsafe living environment, and unaddressed mildew at the facility.
Findings
After physical plant tours, staff and resident interviews, and observations, there was insufficient evidence to substantiate any of the allegations. The facility was found to have sufficient living space, safe living environment with adequate pull alarms, and no mildew issues in the alleged rooms. The complaint was determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated based on observations and interviews. Allegations included insufficient living space, unsafe living environment due to shared pull alarm, and mildew presence in rooms #228 and #214. None of these were verified during the investigation.
Report Facts
Residents interviewed: 9
Residents interviewed: 95
Staff interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during the visit |
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted physical plant tours and interviews during investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 0
Mar 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not properly addressing an issue with bedbugs at the facility.
Findings
The investigation found that resident #1's room had been treated for bedbugs by a pest control service and that residents and staff reported no recent sightings of bedbugs. Based on observations and interviews, there was insufficient evidence to verify the allegation, and it was deemed unsubstantiated.
Complaint Details
The complaint alleged that staff were not properly addressing the bedbug issue. The investigation included interviews with residents and staff, a physical plant tour, and document review. The allegation was found to be unsubstantiated.
Report Facts
Complaint Control Number: 31
Residents interviewed: 9
Staff interviewed: 5
Days between treatments: 14
Days between initial treatment and follow-up visit: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted physical plant tour and interviews during investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 100
Deficiencies: 0
Mar 19, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations including staff stealing resident's money, cutting resident's hair without consent, neglecting resident hygiene, and not assisting a resident in a timely manner.
Findings
All allegations were found to be unsubstantiated based on interviews, record reviews, and observations. Resident funds were accounted for, no evidence of unauthorized haircuts or neglect of hygiene was found, and staff were reported to assist residents in a timely manner.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff stealing resident's money, cutting hair without consent, neglecting hygiene, and failure to assist in a timely manner. Investigations included interviews with staff and residents, record reviews, and physical plant tour. No evidence supported the allegations.
Report Facts
Residents interviewed: 10
Facility capacity: 100
Facility census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leizl De La Cerra | Licensing Program Analyst | Conducted the complaint investigation |
| Imelda Villanueva | Administrator | Met with Licensing Program Analyst during investigation |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 93
Capacity: 100
Deficiencies: 0
Mar 18, 2025
Visit Reason
The inspection visit was an unannounced site visit continuation of the required annual inspection conducted on 03/17/2025 to evaluate the facility's compliance with licensing requirements.
Findings
The inspection found that resident bedrooms, bathrooms, surrounding grounds, laundry facilities, medication storage, resident and staff records were all in compliance with safety, privacy, and regulatory standards. No immediate health or safety hazards were observed during the inspection.
Report Facts
Resident files reviewed: 10
Staff files reviewed: 6
Medication Administration Records reviewed: 6
Laundry machines: 8
Hot water temperature range: 112.3
Hot water temperature range: 113.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Imelda Villanueva | Administrator | Met with Licensing Program Analysts during the inspection. |
| Nadia Shahbazian | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Raymond Comer | Licensing Program Analyst | Conducted the inspection. |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 93
Capacity: 100
Deficiencies: 0
Mar 17, 2025
Visit Reason
An unannounced required annual inspection was conducted by Licensing Program Analysts to evaluate the facility's compliance with licensing requirements.
Findings
The facility was observed to be clean, sanitary, and appropriately furnished with all required fire detection and protection systems in place. The kitchen and common areas were clean and well-maintained. Due to time constraints, the inspection was not completed and will be finished at a later date.
Report Facts
Fire extinguisher service date: Apr 3, 2024
Last disaster drill date: Dec 17, 2024
Last fire inspection date: May 13, 2024
Perishable food supply duration (days): 2
Non-perishable food supply duration (days): 7
Hospice waiver capacity: 30
Non-ambulatory resident capacity: 100
Bedridden resident capacity: 10
Number of exit doors: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Imelda Villanueva | Administrator | Met with Licensing Program Analysts during inspection and received exit interview |
| Nadia Shahbazian | Licensing Program Analyst | Conducted the inspection |
| Raymond Comer | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 100
Deficiencies: 0
Mar 4, 2025
Visit Reason
The visit was an unannounced case management visit conducted in conjunction with a collateral visit for complaint #31-AS-20250303144817 to ensure the health and safety of three residents relocated from another facility.
Findings
The Licensing Program Analyst and Manager toured the facility, interviewed the administrator and residents, and reviewed pertinent records. Interviews revealed that one resident had left the facility, and the remaining residents reported satisfaction with their care and that their needs were met.
Complaint Details
Complaint #31-AS-20250303144817 triggered the visit to ensure the health and safety of three residents relocated from Rossmoyne Hills.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the unannounced case management visit and facility tour. |
| Naira Margaryan | Licensing Program Manager | Conducted the unannounced case management visit and exit interview. |
| Nirjara Acharya | Administrator | Interviewed during the visit regarding resident status. |
| Imelda Villanueva | Met with during the visit. |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 0
Jan 23, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations of neglect in care and supervision that contributed to a resident's death.
Findings
Based on record reviews and interviews with staff and residents, there was insufficient evidence to verify the allegation of neglect. The allegation was determined to be unsubstantiated. No health and safety hazards were noted during the visit.
Complaint Details
The complaint alleged neglect in care and supervision contributing to a resident's death, including claims that a resident's roommate tried to assist while choking but was unsuccessful, and that staff response to the call for help was delayed by ten hours. The investigation found no substantiation for these claims.
Report Facts
Caregivers on duty: 3
MedTech on duty: 1
Staff interviewed: 5
Residents interviewed: 9
Time staff responded: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 0
Dec 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/27/2024 regarding facility disrepair, odor issues, unmet toileting needs, lack of dignity and respect from staff, and absence of daily activities for residents.
Findings
After a physical plant tour, interviews with staff and residents, and record reviews, the investigation found insufficient evidence to substantiate any of the allegations. The facility was found to have addressed the leaking toilet promptly, no consistent malodor was detected, residents' toileting needs were reportedly met, staff treated residents with dignity, and daily activities were provided. No health or safety hazards were noted.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included facility disrepair, odor issues, unmet toileting needs, disrespectful staff behavior, and lack of activities. Investigations included interviews with five staff and nine residents, physical plant tours, and document reviews. All allegations were found unsubstantiated based on observations and interviews.
Report Facts
Complaint control number: 31-AS-20240927130858
Number of staff interviewed: 5
Number of residents interviewed: 9
Leak repair duration (days): 5
Staff toileting check frequency (hours): 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on report |
| Imelda Villanueva | Facility representative met during investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 100
Deficiencies: 1
Dec 9, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff forced a resident to cut their hair without consent.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff violated resident's personal rights by cutting hair without family permission, failing to update service plan and notify Power of Attorney. | Type B |
Report Facts
Capacity: 100
Census: 93
Deficiency Type: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Ngo-Castaneda | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation |
| Imelda Villanueva | Executive Director | Facility representative interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 100
Deficiencies: 0
Dec 3, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff handled residents in a rough manner and were not addressing residents' dental needs.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with residents, staff, and administrators, as well as record reviews, did not corroborate the claims, and both allegations were deemed unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included rough handling of a resident and neglect of dental needs. No witnesses or corroborating evidence were found, and the resident involved had moved out prior to the investigation.
Report Facts
Capacity: 100
Census: 93
Complaint Control Number: 31-AS-20241106121450
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Gary Tan | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named in report as Licensing Program Manager |
| Nirjara Acharya | Administrator | Facility administrator who denied allegations |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 100
Deficiencies: 0
Nov 15, 2024
Visit Reason
An unannounced initial 10-day complaint visit was conducted to investigate allegations that staff mishandled a resident's personal belongings and medications.
Findings
The investigation found that the resident did not provide prior notification or consent for assistance with belongings or medications. Staff secured the resident's belongings and medications properly, and interviews with staff, residents, and family confirmed satisfactory handling. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint alleged staff mishandled a resident's personal belongings and medications. The investigation revealed the resident refused assistance and did not sign medical release forms. Staff stored belongings and medications securely, and family planned to pick them up. The allegations were unsubstantiated.
Report Facts
Capacity: 100
Census: 90
Residents interviewed: 8
Staff interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Imelda Villanueva | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 0
Nov 12, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not properly supervise a resident, resulting in the resident falling.
Findings
The allegation was found to be unsubstantiated based on interviews, observations, and record reviews. No falls or injuries were reported or witnessed, and the resident was not left unsupervised. No citations were issued.
Complaint Details
The complaint alleged that staff did not properly supervise a resident who fell. The investigation included interviews with residents, staff, and the administrator, as well as record reviews. The allegation was deemed unsubstantiated as no evidence supported the claim.
Report Facts
Capacity: 100
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lorena Casillas | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nichelle Gillyard | Licensing Program Manager | Named in report as Licensing Program Manager |
| Imelda Villanueva | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 0
Oct 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/02/2024 regarding staff not ensuring residents' personal property was safeguarded and a facility bathroom being in disrepair.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with staff and residents, record reviews, and physical inspections showed no indication of theft or bathroom disrepair. Both allegations were determined to be unsubstantiated.
Complaint Details
The complaint involved allegations that staff did not safeguard residents' personal property and that a common bathroom was in disrepair for four days. After interviews, record reviews, and observations, both allegations were found unsubstantiated.
Report Facts
Complaint control number: 31-AS-20240702155732
Number of staff interviewed: 4
Number of residents interviewed: 9
Days bathroom allegedly out of order: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
| Imelda Villanueva | Executive Director | Met with during the investigation visit |
| Nirjara Acharya | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 100
Deficiencies: 0
Oct 23, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff do not ensure room temperatures are maintained at 68 degrees as required.
Findings
The investigation included interviews with residents and staff, and observation of thermostats. It was found that room temperatures varied between 72 and 78 degrees Fahrenheit, with some residents feeling cold at night and others preferring cooler or warmer temperatures. The complaint was deemed unsubstantiated based on these findings.
Complaint Details
The complaint alleged that staff do not maintain room temperatures at 68 degrees. Interviews revealed mixed resident experiences with temperature comfort, and thermostat settings were observed to be between 72 and 78 degrees. The complaint was determined to be unsubstantiated.
Report Facts
Residents interviewed: 15
Staff interviewed: 5
Facility capacity: 100
Facility census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Evelin Rios | Licensing Program Analyst | Conducted the complaint investigation. |
| Imelda Villanueva | Executive Director | Met with the Licensing Program Analyst during the investigation and provided information. |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 100
Deficiencies: 0
Oct 9, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-07-02 regarding staff not meeting residents' care needs, not providing a safe environment, inappropriate communication with residents, and inability to communicate effectively with residents.
Findings
Based on observations, interviews with staff and residents, and a physical plant tour, there was insufficient evidence to substantiate any of the allegations. No health or safety hazards were noted, and all interviewed residents and staff reported appropriate care and communication.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff ignoring residents' calls for help, unsafe environment due to a flipped rug, staff being rude or dismissive, and staff unable to communicate effectively in English. Investigations included interviews with four staff and nine residents, and a physical plant tour. All allegations were found unsubstantiated based on the evidence.
Report Facts
Staff interviewed: 4
Residents interviewed: 9
Complaint received date: Jul 2, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Imelda Villanueva | Executive Director | Met with during the investigation visit |
| Nirjara Acharya | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 100
Deficiencies: 0
Sep 12, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate multiple allegations regarding staff safeguarding resident's personal belongings, consulting with resident's authorized representative, providing records, and meeting resident's hygiene and diapering needs.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Staff were found to have safeguarded resident's personal belongings, consulted appropriately regarding document signing, provided requested records to the authorized representative, and met the resident's hygiene and diapering needs.
Complaint Details
The complaint investigation addressed allegations including failure to safeguard resident's personal belongings, failure to consult with resident's authorized representative regarding document signing, failure to provide records to the authorized representative, and failure to meet resident's hygiene and diapering needs. All allegations were deemed unsubstantiated based on interviews, record reviews, and observations.
Report Facts
Unaccounted funds: 3400
Residents interviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Cava | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during investigation and provided information regarding allegations. |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 100
Deficiencies: 0
Jul 3, 2024
Visit Reason
An unannounced complaint investigation was conducted based on allegations that staff did not ensure resident's grab bars were in good repair resulting in falls, and that staff were emotionally abusing a resident.
Findings
The investigation found insufficient information to support the allegations. Interviews with residents and staff, physical inspection of grab bars, and review of maintenance reports indicated grab bars were in good repair and residents felt safe. No evidence of emotional abuse was observed or reported.
Complaint Details
The complaint was unsubstantiated. Allegations included unsafe grab bars causing falls and emotional abuse of a resident. Both allegations were found unsupported after interviews, observations, and document review.
Report Facts
Capacity: 100
Census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during investigation |
| Nirjara Acharya | Administrator | Facility administrator named in report header |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 100
Deficiencies: 0
Jun 25, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff does not safeguard resident’s personal belongings.
Findings
The investigation included physical plant inspection, interviews, and review of facility documents and cameras. The allegation was found to be unsubstantiated due to insufficient evidence and conflicting statements from the resident.
Complaint Details
The complaint alleged that staff did not safeguard resident’s personal belongings. The investigation found no evidence to support the allegation, and it was determined to be unsubstantiated.
Report Facts
Capacity: 100
Census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation visit |
| Imelda Villanueva | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 100
Deficiencies: 0
Jun 25, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not prevent a resident from disturbing another resident.
Findings
The investigation found that the facility staff relocated the resident causing disturbance to a different room to resolve the conflict. Interviews confirmed the issue was resolved, and the allegation was unsubstantiated.
Complaint Details
The complaint alleged that staff did not prevent a resident from disturbing another resident. The allegation was found to be unsubstantiated based on interviews and actions taken by the facility.
Report Facts
Capacity: 100
Census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Imelda Villanueva | Facility representative met during the investigation | |
| Nirjara Acharya | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 100
Deficiencies: 0
May 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations of staff verbally and financially abusing residents at the facility.
Findings
The investigation found no substantiation for the allegations. Interviews with residents and staff revealed no evidence of verbal abuse, and the financial abuse allegation was classified as a false report by local law enforcement.
Complaint Details
The complaint involved allegations of staff verbally abusing a resident and financially abusing a resident in care. The allegations were deemed unsubstantiated based on interviews and evidence gathered.
Report Facts
Residents interviewed: 15
Complaint control number: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during the investigation |
| Troy Agard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 100
Deficiencies: 0
May 29, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding the allegation that the facility did not refund the unused portion of a resident's rent.
Findings
The investigation found insufficient information to support the allegation. The facility staff communicated with the resident regarding the refund, and the corporate office was processing the refund. No health and safety hazards were noted during the visit.
Complaint Details
The allegation was that the facility did not refund resident R1's prorated rent after moving out on 04/09/2024 without providing a notice of intent to vacate. The refund amount was calculated, and the corporate office was processing a refund check of $784.84. Attempts to interview the resident were unsuccessful. The allegation was unsubstantiated.
Report Facts
Resident monthly rate: 1418.07
Daily rate: 47.27
Days calculated for refund: 21
Previous balance: 207.81
Refund amount: 784.84
Capacity: 100
Census: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 100
Deficiencies: 0
May 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations received on 2023-05-09 regarding unlawful eviction, staff behavior, facility disrepair, mail withholding, safeguarding of belongings, and residents smoking inside the facility.
Findings
The investigation included interviews with staff and residents, review of records, and facility observations. All allegations were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred. No deficiencies were cited.
Complaint Details
The complaint included allegations of unlawful eviction, inappropriate staff speech to residents, facility disrepair, staff withholding resident mail, failure to safeguard resident belongings, and residents smoking inside the facility. All allegations were investigated through interviews with staff (S1-S5) and residents (R1-R10), record reviews, and facility tours. Each allegation was found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 100
Census: 88
Staff interviewed: 5
Residents interviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Imelda Villanueva | Administrator | Facility administrator present during the investigation and exit interview |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 100
Deficiencies: 0
May 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-09-11 alleging that staff do not accord resident privacy and staff are not assisting residents with care needs.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with staff and residents indicated that residents are accorded privacy and receive assistance with their care needs according to their care plans. Therefore, both allegations were unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint alleged that staff do not accord resident privacy and staff are not assisting residents with care needs. After interviews with staff (S1-S4) and residents (R1-R10), and review of relevant documents, the allegations were found unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 100
Census: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation and subsequent visit |
| Imelda Villanueva | Administrator | Met with during exit interview and named in report |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 100
Deficiencies: 0
May 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-09-19 regarding multiple allegations about staff conduct and resident care at Burbank Senior Villa East.
Findings
The investigation included interviews with staff and residents, review of records, and observations. All allegations, including inadequate storage space, lack of assistance after a fall, lack of dignity in personal relationships, inappropriate staff communication, and medication dispensing issues, were found to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint included five allegations: 1) Staff does not ensure resident has adequate storage space for personal belongings; 2) Resident was not accorded assistance by staff after having fallen; 3) Staff does not ensure resident is accorded dignity in personal relationships with staff and residents; 4) Staff do not ensure resident is spoken to in an appropriate manner; 5) Staff do not ensure medications are dispensed as prescribed to resident in care. All allegations were investigated and found unsubstantiated.
Report Facts
Complaint Allegations: 5
Resident Refusal Period: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Marili Barajas | Business Office Manager | Facility representative who participated in the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 100
Deficiencies: 0
May 14, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations including failure to provide requested records to a resident's responsible party, falsification of documents, and failure to provide proper notice of rate increase.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Records requested by the resident's responsible party were provided, no document falsification was found, and although the rate increase notice lacked a date, it was distributed to residents and discussed in a resident council meeting. No deficiencies were cited.
Complaint Details
The complaint involved three allegations: 1) staff did not provide requested records to resident's responsible party, 2) staff falsified documents, and 3) staff did not provide proper notice of rate increase. The investigation concluded all allegations were unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 100
Census: 88
Outstanding balance: 215
Retirement benefit: 185
Payment amount: 1327.82
Payment amount: 400
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Imelda Villanueva | Administrator | Met during investigation and named in findings |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nirjara Acharya | Regional Director | Met during initial 10-day visit related to investigation |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 100
Deficiencies: 0
May 14, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not prevent a resident from causing harm to another resident and that a visitor vandalized a resident's room while in care.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with staff, residents, and the Executive Director, along with records review, did not corroborate the claims of harm or vandalism. The allegations were therefore unsubstantiated.
Complaint Details
The complaint involved two allegations: 1) Staff did not prevent a resident from causing harm to another resident, and 2) A visitor vandalized a resident's room. Both allegations were investigated through interviews and records review. The first allegation was denied by staff and residents, and no evidence supported it. The second allegation involved an incident where a room divider was cracked, but no other damage was documented or corroborated. There was no photographic or surveillance evidence. Both allegations were deemed unsubstantiated.
Report Facts
Complaint Control Number: 31
Room changes for resident R2: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Imelda Villanueva | Executive Director | Interviewed regarding allegations and exit interview conducted |
| Nirjara Acharya | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 0
May 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to address allegations including failure to order a resident's oxygen tank, a resident sustaining a stage 1 pressure injury due to staff neglect, staff retaliation against a resident's authorized representative, and a resident's air conditioning being in disrepair.
Findings
The investigation found no sufficient evidence to support any of the allegations. Interviews with residents, staff, and the administrator, as well as record reviews and facility inspections, indicated that the resident had access to oxygen equipment, did not sustain a pressure injury due to neglect, no retaliation occurred, and the air conditioning units were functional. Therefore, all allegations were unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint included four allegations: 1) Staff did not order resident's oxygen tank; 2) Resident sustained a stage 1 pressure injury due to staff neglect; 3) Staff retaliated against resident due to authorized representative asking questions about care; 4) Resident's air conditioning was in disrepair. The investigation concluded all allegations were unsubstantiated.
Report Facts
Capacity: 100
Census: 87
Number of allegations: 4
Number of residents interviewed: 8
Number of staff interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Imelda Villanueva | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 0
May 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations regarding resident care and facility conditions at Burbank Senior Villa East.
Findings
The investigation found no sufficient evidence to substantiate any of the allegations including rough handling of a resident, lack of closet space, malodorous rooms, inadequate showering and incontinence care, exposure to maintenance dust, and pest issues. The allegations were determined to be unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint included allegations that staff handled a resident roughly, failed to ensure closet space, allowed malodorous rooms, did not shower or assist with incontinence timely, exposed residents to maintenance dust, and failed to keep rooms free of roaches. Interviews with residents, staff, and the administrator, as well as record reviews and inspections, found no evidence to support these claims. The complaint was unsubstantiated.
Report Facts
Residents interviewed: 8
Staff interviewed: 4
Resident bathing frequency: 3
Facility capacity: 100
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Imelda Villanueva | Administrator | Met during inspection and interviewed regarding allegations |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Nirjara Acharya | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 0
May 10, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-06-30 alleging that staff do not distribute residents' medications as prescribed, do not meet residents' dietary needs, and do not assist residents with bathing.
Findings
The investigation included interviews with residents, staff, and the Executive Director, as well as reviews of medication administration records, dietary menus, and ADL logs. All allegations were found to be unsubstantiated based on evidence gathered, including resident and staff interviews and documentation reviews.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to distribute medications as prescribed, failure to meet dietary needs, and failure to assist with bathing. Interviews and record reviews did not support these allegations.
Report Facts
Census: 87
Total Capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during the investigation and provided information denying allegations |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation and interviews |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 0
May 10, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-01-16 alleging that staff does not prevent a resident from disturbing another resident.
Findings
The investigation included interviews with residents, staff, and the Executive Director, as well as a facility tour. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, with no immediate health or safety concerns observed.
Complaint Details
The complaint alleged that residents were having loud conversations outside a peer’s bedroom while the peer was sleeping. Interviews with residents and staff denied the allegation, and the Executive Director reported that residents are asked to keep noise down and staff conduct rounds every 2 hours with de-escalation procedures if needed. The allegation was unsubstantiated.
Report Facts
Complaint Control Number: 31-AS-20240116144428
Number of residents interviewed: 8
Number of staff interviewed: 4
Rounds frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Imelda Villanueva | Executive Director | Interviewed regarding the allegation and participated in exit interview |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 100
Deficiencies: 0
May 10, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2023-08-08 alleging that a resident sustained unexplained injuries while in care.
Findings
The investigation included interviews with residents, staff, and the Executive Director, as well as review of relevant records. The allegation of unexplained injuries was found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
Allegation: Resident sustained unexplained injuries while in care. The resident allegedly had an un-witnessed fall on 2023-08-04 resulting in a swollen left cheek and bruised eye. Interviews with residents and staff denied the allegation, and the Executive Director was unaware of the fall until hospital notification. The resident had no recollection of the fall at the hospital. The allegation was unsubstantiated.
Report Facts
Complaint Control Number: 31
Capacity: 100
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Imelda Villanueva | Executive Director | Interviewed during investigation and exit interview |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on report |
| Nirjara Acharya | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 100
Deficiencies: 0
Apr 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2024-04-19 regarding elevator maintenance and resident transportation issues.
Findings
The investigation found the elevator was operational during the visit and maintained regularly, with only short outages documented, thus the elevator maintenance allegation was unsubstantiated. The allegation that a resident missed a scheduled appointment due to lack of transportation was also unsubstantiated as records showed no appointment on the alleged date and transportation services were provided as needed.
Complaint Details
The complaint included allegations that the facility elevators were not maintained in operating condition and that staff did not ensure a resident attended a scheduled appointment. Both allegations were found to be unsubstantiated based on observations, document reviews, and interviews.
Report Facts
Facility capacity: 100
Census: 90
Elevator outage duration: 1
Transportation days per week: 3
Residents interviewed: 9
Staff interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Huma Rahimi | Licensing Program Analyst | Conducted the complaint investigation |
| Imelda V. Villanueva | Administrator | Met with Licensing Program Analyst during investigation |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 97
Capacity: 100
Deficiencies: 0
Mar 17, 2024
Visit Reason
An unannounced required one-year inspection was conducted to evaluate compliance with licensing regulations and infection control plans at the facility.
Findings
The facility was found to be in compliance with health and safety standards, including proper infection control measures, secure storage of medications and toxins, adequate food supplies, and well-maintained physical plant and resident rooms. No health and safety issues were observed.
Report Facts
Food supply duration: 2
Food supply duration: 7
Resident files reviewed: 5
Staff files reviewed: 6
Hot water temperature range: 108.9
Hot water temperature range: 116.6
Fire extinguisher last service date: Mar 31, 2023
Facility disaster drill date: Feb 21, 2024
Fire inspection date: Jun 15, 2023
Fire inspection validity: Oct 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Imelda Villanueva | Executive Director | Met with Licensing Program Analysts during inspection |
| Reyna Garcia | Wellness Coordinator | Participated in physical plant tour during inspection |
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the inspection |
| Gary Tan | Licensing Program Analyst | Conducted the inspection |
| Naira Margaryan | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 100
Deficiencies: 0
Feb 14, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff do not treat a resident with respect.
Findings
The investigation found insufficient evidence to substantiate the allegation. Staff and most residents reported respectful treatment, and no health or safety hazards were noted during the visit.
Complaint Details
The allegation that staff dismiss Resident #1 and fail to address an electrical issue was unsubstantiated based on interviews and observations.
Report Facts
Number of staff interviewed: 4
Number of residents interviewed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during the visit |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 100
Deficiencies: 0
Feb 14, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff do not provide adequate hygiene care to a resident.
Findings
The investigation found no evidence to substantiate the allegation; residents were observed to be clean and well-groomed, and staff and resident interviews confirmed adherence to shower schedules. No health or safety hazards were noted.
Complaint Details
The allegation that staff did not provide adequate hygiene care to Resident #1 was unsubstantiated based on observations and interviews during the investigation.
Report Facts
Residents interviewed: 10
Staff interviewed: 4
Residents census: 97
Facility capacity: 100
Shower frequency: 2
Shower frequency: 3
Residents independent of shower assistance: 3
Residents with shower schedule: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 100
Deficiencies: 0
Jan 17, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-10-27 regarding pest infestation and staff stealing residents' personal belongings.
Findings
The investigation found that the facility had a contracted pest control company inspecting twice monthly and no residents reported seeing roaches. Regarding theft allegations, records showed no declared missing items, a police report indicated a false report of theft, and interviewed residents reported no missing belongings. The allegations were deemed unsubstantiated.
Complaint Details
The complaint involved allegations that staff did not keep the facility free of insects and that staff were stealing residents' personal belongings. The investigation found no evidence to substantiate these allegations.
Report Facts
Residents interviewed: 10
Complaint received date: Oct 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during investigation |
| Troy Agard | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 100
Deficiencies: 0
Jan 8, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility did not take necessary precautions to prevent the spread of COVID-19.
Findings
The investigation found that the facility followed COVID-19 protocols, including isolating positive residents, providing masks, and requiring staff to stay home until testing negative. Interviews and record reviews indicated precautions were taken, and the allegation was unsubstantiated.
Complaint Details
The complaint alleged that the facility failed to prevent the spread of COVID-19, including residents being in common areas while positive and staff working while diagnosed. The allegation was found to be unsubstantiated based on inspection, interviews, and record review.
Report Facts
Capacity: 100
Census: 94
Number of residents interviewed: 6
Number of staff interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar-Ettima | Licensing Program Analyst | Conducted the complaint investigation visit |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 100
Deficiencies: 1
Dec 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a questionable death of a resident who jumped off the rooftop, financial abuse, failure to prevent harm between residents, and failure to provide a safe and comfortable environment.
Findings
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 Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure that the rooftop was locked and inaccessible to residents, resulting in a resident jumping off the rooftop causing hospitalization and death. This posed an immediate health, safety, and personal rights risk to residents. | Type A |
Report Facts
Capacity: 100
Census: 99
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Troy Agard | Licensing Program Manager | Oversaw the complaint investigation |
| Nirjara Acharya | Administrator | Facility administrator involved in investigation and interviews |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during investigation |
| Dennis Douglas | Investigator | Investigated the incident and interviewed staff and officials |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 100
Deficiencies: 0
Nov 20, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 11/13/2023 regarding disrepair of a resident's bathroom and staff not providing residents with towels.
Findings
The investigation found no sufficient evidence to support the allegations. The bathroom in room #209 was observed to have a functioning shower head, and residents confirmed availability of towels, although sometimes with a delay. The allegations were determined to be unsubstantiated with no immediate health and safety hazards noted.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included a resident's bathroom being in disrepair and staff not providing towels. Interviews with residents and staff, as well as physical inspection, did not support these claims.
Report Facts
Capacity: 100
Census: 97
Residents interviewed: 10
Staff interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Imelda Villanueva | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 100
Deficiencies: 0
Nov 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff do not respond to residents' call buttons in a timely manner.
Findings
The investigation included interviews with staff and residents, testing of call buttons, and review of resident files. It was found that staff responded to call buttons within three to eight minutes, and residents reported mixed experiences but generally timely responses. The allegation was determined to be unsubstantiated with no immediate health and safety hazards noted.
Complaint Details
The complaint alleged that staff do not respond to residents' call buttons in a timely manner, sometimes taking two hours or never responding. The allegation was found to be unsubstantiated based on observations, interviews, and testing during the visit.
Report Facts
Residents interviewed: 10
Staff interviewed: 3
Call response time: 3
Call response time: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Imelda Villanueva | Executive Director | Met with the Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 100
Deficiencies: 0
Nov 3, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff were forcing a resident to move rooms.
Findings
The investigation found that the resident had signed an admission agreement for a shared room and that the resident requested the move due to roommate issues. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff were forcing Resident #1 to move from a single room to a shared room. Interviews and document reviews revealed the resident voluntarily requested the move due to roommate problems. The allegation was unsubstantiated.
Report Facts
Capacity: 100
Census: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gina Saucedo | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Agard | Licensing Program Manager | Named in report signature and oversight |
| Nirjara Acharya | Administrator | Facility administrator met during investigation |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 100
Deficiencies: 2
Aug 25, 2023
Visit Reason
Unannounced investigation of a complaint received on 2021-07-19 regarding a resident sustaining pressure injuries while in care.
Findings
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.
Complaint Details
Complaint substantiated. Resident #1 sustained pressure injuries while in care, with evidence showing inadequate care and worsening of pressure ulcers. Civil penalties were assessed.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Persons who require health services for or have a health condition including stage 3 and 4 pressure injuries shall not be admitted or retained in a residential care facility for the elderly. | Type A |
| Residents shall have the right to care, supervision, and services that meet their individual needs and are delivered by sufficient, qualified, and competent staff. Resident #1's needs were not met due to insufficient staffing. | Type B |
Report Facts
Capacity: 100
Census: 99
Deficiency Type A: 1
Deficiency Type B: 1
Plan of Correction Due Date: Aug 30, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation and issued the report |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation report |
| Michael Sokolowski | Administrator | Facility administrator involved in the investigation |
| Imelda Villanueva | Facility representative who assisted during the visit |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 100
Deficiencies: 3
Aug 16, 2023
Visit Reason
This was an unannounced complaint investigation visit conducted due to allegations received on 2021-01-06 regarding neglect and inadequate care of a resident resulting in hospitalization and pressure injuries.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to regularly observe residents for changes in physical, mental, emotional and social functioning and to provide appropriate assistance when unmet needs are revealed, including failure to document and report changes to the resident's physician and responsible person. | Type A |
| Failure to provide adequate care resulting in resident developing stage 2 pressure injuries likely from not being turned. | Type A |
| Failure to provide adequate nutrition and hydration resulting in dehydration and malnutrition. | Type A |
Report Facts
Civil penalty amount: 500
Capacity: 100
Census: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joe Katrdzhyan | Licensing Program Analyst | Conducted the unannounced follow-up visit and investigation. |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation. |
| Michael Sokolowski | Administrator | Facility administrator during the investigation. |
| Imelda Villanueva | Administrator | Assisted with the visit. |
| Lorraine Patterson | Investigator | Conducted the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 100
Deficiencies: 2
Aug 2, 2023
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations including a resident missing scheduled optometrist appointments and staff not addressing a resident's change in medical condition, as well as allegations of improper maintenance of a resident's room and inappropriate staff speech towards a resident.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide transportation for resident's scheduled optometrist appointment. | Type B |
| Failure to update pre-admission appraisal to reflect resident's change in medical condition related to vision. | Type B |
Report Facts
Capacity: 100
Census: 98
Deficiencies cited: 2
Plan of Correction Due Date: Aug 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joe Katrdzhyan | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Michael Sokolowski | Administrator | Facility administrator named in the report |
| Marili Barajas | Office Manager | Met with Licensing Program Analyst during investigation |
| Imelda Viilanueva | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 100
Deficiencies: 0
Jul 28, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff unlawfully evicted a resident.
Findings
The investigation found insufficient evidence to support the allegation of unlawful eviction. The 30-day eviction notice issued was lawful, and the resident voluntarily moved out independently after declining assistance from staff.
Complaint Details
The complaint alleged that staff unlawfully evicted resident #1 due to nonpayment of rent. The investigation included interviews with the resident and staff, review of eviction notices, payment invoices, and other relevant documents. The allegation was found to be unsubstantiated.
Report Facts
Capacity: 100
Census: 96
Complaint Control Number: 28-AS-20210416101629
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bonnie Tao | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Imelda Villanueva | Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Michael Sokolowski | Administrator | Named as facility administrator in report header |
| Marili Barajas | House Manager | Interviewed regarding eviction notice and resident status |
| Fernando Fierros | Licensing Program Manager | Named in report |
| Gail Johnson | Licensing Program Analyst | Conducted a prior complaint investigation visit referenced in the report |
Inspection Report
Annual Inspection
Census: 99
Capacity: 100
Deficiencies: 0
Jun 24, 2023
Visit Reason
An unannounced required one-year inspection was conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be well-maintained with no health and safety issues observed. Resident rooms were adequately furnished, safety measures were in place, medications were securely stored, and emergency plans were reviewed. Staff and resident files appeared complete and updated.
Report Facts
Food supply duration: 2
Food supply duration: 7
Hot water temperature range: 111.2
Hot water temperature range: 113.3
Resident files reviewed: 5
Staff files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nirjara Acharya | Regional Director | Met with Licensing Program Analysts during inspection |
| Imeda Villanueva | Executive Director | Met with Licensing Program Analysts during inspection |
| Antonia Alvizar | Licensing Program Analyst | Conducted the inspection |
| Gary Tan | Licensing Program Analyst | Conducted the inspection |
| Naira Margaryan | Licensing Program Manager | Named in report |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 100
Deficiencies: 0
Jun 12, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that residents were smoking marijuana in the facility and that the facility failed to provide a comfortable environment.
Findings
The investigation found no sufficient evidence to substantiate the allegations. No marijuana odor was detected during the physical plant tour, staff denied witnessing smoking inside the facility, and residents were divided on smelling marijuana but none witnessed smoking indoors. One resident admitted to smoking marijuana outside the facility. No immediate health and safety hazards were noted.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included residents smoking marijuana inside the facility and failure to provide a comfortable environment. Interviews with staff and residents, as well as physical inspection, did not support these claims.
Report Facts
Capacity: 100
Census: 96
Staff interviewed: 6
Residents interviewed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonia Alvizar | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Imelda Villanueva | Executive Director | Met with the Licensing Program Analyst during the investigation |
| Naira Margaryan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 0
Mar 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-02-10 regarding staff failing to administer medication as prescribed and handling residents in a rough manner.
Findings
The investigation included interviews with residents and staff, a physical plant tour, and record reviews. The allegations were found to be unsubstantiated based on interviews and medication records showing no missed medications or rough handling incidents.
Complaint Details
The complaint involved allegations that staff failed to administer medication as prescribed and handled residents roughly. Interviews with residents and staff, as well as record reviews, revealed no evidence supporting these allegations. The complaint was deemed unsubstantiated.
Report Facts
Complaint Control Number: 28-AS-20230210122615
Capacity: 100
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Gary Tan | Evaluator / Licensing Program Analyst | Conducted the complaint investigation visit |
| Nirjara Acharyan | Regional Director | Facility administrator met during the investigation |
| Alex Estrada | Licensing Program Manager | Named in report signature |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 0
Mar 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-02-27 alleging that the facility did not have hot water.
Findings
The Licensing Program Analyst interviewed the Executive Director and conducted a physical inspection of resident and employee bathrooms. Hot water temperatures were found to be within compliance, and although the boiler was initially out of service, repairs were made promptly. The allegation was determined to be unsubstantiated based on inspection and documentation.
Complaint Details
The complaint alleged that the facility did not have hot water. The allegation was found to be unsubstantiated after investigation.
Report Facts
Hot water temperature readings: 105.8
Hot water temperature readings: 107.6
Hot water temperature readings: 110.6
Hot water temperature readings: 111.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nirjara Acharya | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Tuesday Cabiness | Licensing Program Analyst | Conducted complaint investigation and inspection |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 100
Deficiencies: 0
Feb 24, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations received on 12/12/2022 regarding staff not safeguarding resident personal belongings and staff threatening a resident.
Findings
The investigation found insufficient evidence to substantiate the allegations. Interviews with staff and residents, as well as review of records, did not corroborate claims that staff failed to safeguard personal belongings or threatened residents. The allegations were therefore deemed unsubstantiated.
Complaint Details
The complaint involved two allegations: 1) Staff did not safeguard resident personal belongings, specifically an electric scooter allegedly not returned to resident R10; 2) Staff threatened a resident. The investigation included interviews with staff and residents and review of relevant records. All evidence failed to substantiate the allegations, resulting in an unsubstantiated finding.
Report Facts
Capacity: 100
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
| Mariii Barajas | Manager | Met with investigators during the visit |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 100
Deficiencies: 0
Feb 3, 2023
Visit Reason
The visit was an unannounced case management investigation regarding a self-reported incident on 01/27/22 where Resident #1 was found bleeding on the parking lot floor.
Findings
The investigation revealed that Resident #1 fell from the rooftop, which is locked and inaccessible to residents. Emergency services were called immediately, and Resident #1 was hospitalized and later passed away. No health and safety issues were noted during the visit.
Complaint Details
The complaint investigation was triggered by a self-reported incident involving Resident #1 falling from the rooftop and bleeding. The incident was substantiated by interviews and observations.
Report Facts
Capacity: 100
Census: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nirjara Acharya | Administrator | Met with Licensing Program Analyst during the investigation and provided information about the incident |
| Jose Gary Tan | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Alex Estrada | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 100
Deficiencies: 0
Jan 26, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that facility staff did not ensure residents received food on a timely basis, that residents' food had missing items, and that staff threw away residents' items.
Findings
Based on observations, interviews with staff and residents, and records reviewed, there was insufficient pertinent information to support any of the allegations. The allegations were therefore unsubstantiated at this time.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included untimely food delivery, missing food items, and staff throwing away residents' belongings. Interviews with residents and staff, as well as observations, did not support these claims.
Report Facts
Residents interviewed: 10
Staff interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tihesha Smith | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nirjara Acharya | Administrator | Facility administrator interviewed during the investigation |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 100
Deficiencies: 0
Jan 18, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that facility staff yell at residents.
Findings
The investigation found no evidence to support the allegation. Interviews with staff and residents indicated that staff treat residents with dignity and respect, and any loud speaking was due to residents' hearing problems. The allegation was deemed unsubstantiated.
Complaint Details
The allegation was that facility staff yell at residents. After interviews with the Office Manager, MedTech, staff members, and residents, the allegation was found to be unsubstantiated.
Report Facts
Census: 98
Total Capacity: 100
Number of residents interviewed: 10
Number of staff interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation |
| Marili Barajas | Office Manager | Interviewed during the investigation |
| Nichelle Gillyard | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 100
Deficiencies: 0
Jan 18, 2023
Visit Reason
This was an unannounced complaint investigation visit conducted in response to allegations that a resident sustained a fall while in care and that staff did not provide adequate care and supervision to a resident.
Findings
The investigation included interviews with staff and residents, a physical plant walkthrough, and review of facility records. No immediate health and safety issues were observed. Both allegations were deemed unsubstantiated based on interviews and documentation reviewed during the visit.
Complaint Details
The complaint involved two allegations: 1) Resident sustained a fall while in care, and 2) Staff did not provide adequate care and supervision to a resident. Both allegations were investigated and found to be unsubstantiated.
Report Facts
Capacity: 100
Census: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Panushkina | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Marili Barajas | Office Manager | Interviewed during the investigation and involved in reporting incidents |
| Nirjara Acharya | Administrator | Met with Licensing Program Analyst and was informed of the visit reason |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 100
Deficiencies: 0
Dec 19, 2022
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff increased rates without proper notice.
Findings
The investigation found that 6 of 6 residents interviewed received a timely letter about a cost of living increase, understood the reasons for the rent increase, and staff provided documentation supporting the increase. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff increased rates without proper notice. The investigation included interviews with residents and staff, review of documentation, and concluded the allegation was unsubstantiated.
Report Facts
Capacity: 100
Census: 93
Date complaint received: Dec 9, 2022
Date letter sent to residents: Nov 22, 2022
New rental amount: 1324.82
Previous rental amount: 1211.77
SSI increase: 914
SSP increase: 578.82
Total SSI/SSP: 1492
Previous total SSI/SSP: 1365
Resident cost difference 2023: 168
Resident cost difference 2022: 154
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nirjara Acharya | Administrator | Facility administrator present during investigation |
| Marili Barajas | Business Manager | Met with Licensing Program Analyst during investigation |
| Wei Siew Ho | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 100
Deficiencies: 1
Dec 1, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation received on 07/23/2020 that the facility had bed bugs.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met evidenced by bed bug infestation posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 100
Census: 96
Deficiency Type: 1
Plan of Correction Due Date: Dec 15, 2022
Residents reporting bed bugs: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
| Nirjana Acharya | Administrator | Facility administrator who assisted with the visit and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 100
Deficiencies: 0
Dec 1, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 07/23/2020 regarding resident care issues including assistance with showering, room confinement, and room cleanliness.
Findings
The investigation found that although some allegations may have occurred, there was insufficient evidence to substantiate the claims. Residents and staff interviews, record reviews, and physical inspections indicated that showering was generally provided, room confinement was due to infection control precautions, and rooms were cleaned regularly.
Complaint Details
The complaint involved three allegations: 1) Facility staff not assisting a resident with showering needs; 2) Facility staff not allowing a resident to leave their room; 3) Facility staff not keeping the resident's room clean. The investigation concluded these allegations were unsubstantiated.
Report Facts
Resident interviews: 10
Staff interviews: 10
Residents stating not showered twice weekly: 4
Residents stating not allowed to leave room: 1
Residents stating room not cleaned daily: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
| Nirjana Acharya | Administrator | Facility administrator who assisted during the visit |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 100
Deficiencies: 0
Nov 18, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff did not provide adequate care and supervision, made inappropriate comments, did not treat residents with dignity and respect, and failed to ensure an Ombudsman poster was displayed.
Findings
The investigation found that the allegations were unsubstantiated due to lack of preponderance of evidence. Most residents and staff denied the allegations, and the Ombudsman poster was observed and verified to be correctly displayed.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate care and supervision, inappropriate comments, lack of dignity and respect, and missing Ombudsman poster. Interviews with residents and staff mostly denied the allegations, and no evidence was found to support them.
Report Facts
Capacity: 100
Census: 97
Number of allegations: 4
Number of residents interviewed: 9
Number of staff interviewed: 5
Inspection Report
Complaint Investigation
Census: 99
Capacity: 100
Deficiencies: 0
Oct 13, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations regarding staff speaking inappropriately to residents, residents not receiving medications as prescribed, and residents being left in soiled diapers for long periods of time.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff were not found to have spoken inappropriately to residents, residents were being administered medications as prescribed, and residents were not left in soiled diapers for long periods of time. All allegations were found to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inappropriate staff communication with residents, failure to provide medications as prescribed, and neglect in leaving residents in soiled diapers. Interviews, document reviews, and observations did not support these allegations.
Report Facts
Capacity: 100
Census: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst (LPA)/Retired Annuitant (RA) | Conducted the complaint investigation visit |
| Marili Barrajas | Office Manager | Met with the investigator and participated in interviews |
| Michael Sokolowski | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 100
Deficiencies: 0
Oct 13, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that a resident contracted infections while in care resulting in hospitalization.
Findings
The investigation found that the facility conducted proper COVID testing and there was no evidence to substantiate the allegation that the resident contracted infections while in care resulting in hospitalization. The allegation was found to be unsubstantiated.
Complaint Details
The complaint alleged that a resident contracted infections while in care resulting in hospitalization. The investigation included interviews with staff and residents, and review of relevant documents. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 100
Census: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst | Conducted the complaint investigation |
| Marili Barrajas | Office Manager | Met with the investigator and participated in the investigation |
| Michael Sokolowski | Administrator | Facility administrator named in the report |
| Araceli Ramirez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 100
Deficiencies: 0
Oct 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 08/18/2021 regarding resident care concerns including pressure injuries, rough handling by staff, failure to treat residents with dignity, and inappropriate comments toward residents.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations did or did not occur, resulting in all allegations being unsubstantiated. Previous related allegations involving inappropriate comments were substantiated but addressed with corrective action and staff termination.
Complaint Details
The complaint involved multiple allegations: resident sustained pressure injuries while in care, staff handled resident in a rough manner, staff failed to treat residents with dignity and respect, and staff made inappropriate comments toward resident. The investigation included interviews with residents, staff, and review of medical and hospice documentation. The allegations were found unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 100
Census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Michael Sokolowski | Administrator | Facility administrator named in the report |
| Nirjara Acharya | Administrator | Met with Licensing Program Analyst during the investigation |
| Marili Barajas | Office Manager | Met with Licensing Program Analyst during the investigation |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 100
Deficiencies: 0
Oct 11, 2022
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff did not address an open sore on a resident's buttock in a timely manner.
Findings
The investigation included interviews with residents and staff, and review of relevant documents. It was found that the resident with the sore was sent to urgent care on the same day the sore was noticed, and an unusual incident report was submitted. There was insufficient evidence to prove the allegation, and it was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff did not timely address an open sore on a resident's buttock. Interviews and document review showed the resident was sent to urgent care on the same day the sore was noticed, and follow-up care was planned. The allegation was unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 100
Census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Marili Barajas | Administrator / Business Manager | Met with Licensing Program Analyst during the investigation |
| Stefanie Coronel | Licensing Program Manager | Named in report signature and oversight |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 100
Deficiencies: 0
Sep 1, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-08-18 regarding resident care issues including pressure injuries, rough handling, lack of dignity and respect, and inappropriate comments by staff.
Findings
The investigation included interviews with residents, staff, and review of medical documentation. The allegations were found to be unsubstantiated due to lack of preponderance of evidence, although some allegations may have been valid. Previous substantiated findings related to inappropriate comments were addressed with staff termination.
Complaint Details
The complaint involved multiple allegations: resident sustained pressure injuries, staff handled residents roughly, failure to treat residents with dignity and respect, and inappropriate comments by staff. The investigation concluded all allegations were unsubstantiated except a prior substantiated finding on inappropriate comments which led to staff termination.
Report Facts
Capacity: 100
Census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation and made subsequent visit |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on report |
| Nirjara Acharya | Administrator | Met with during inspection and interviewed |
| Marili Barajas | Office Manager | Met with during subsequent visit |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 100
Deficiencies: 0
Jun 21, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that residents were being exposed to cigarette smoke while in care.
Findings
The investigation found that residents smoked in a designated smoking area near the main entrance, but staff ensured doors were closed to prevent smoke from entering the facility. Interviews with staff and residents indicated no complaints or adverse effects from cigarette smoke, and no residents were observed smoking inside the facility. Therefore, there was insufficient evidence to substantiate the allegation.
Complaint Details
The complaint alleged that residents were exposed to cigarette smoke near the main entrance door, causing smoke to enter the lobby. The allegation was unsubstantiated based on interviews, observations, and file reviews.
Report Facts
Capacity: 100
Census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Sicairos | Licensing Program Analyst | Conducted the complaint investigation visit |
| Nirjara Acharya | Administrator | Met with Licensing Program Analyst during the investigation |
| Stefanie Coronel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 100
Deficiencies: 1
May 20, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 05/12/2022 regarding elevator malfunction and staff reporting issues at Burbank Senior Villa East.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The elevator phone was not working, preventing a trapped resident from calling for help. | Type B |
Report Facts
Capacity: 100
Census: 97
Deficiency Plan of Correction Due Date: May 27, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Marili Barajas | Manager | Facility manager met with Licensing Program Analyst and was involved in investigation |
| Michael Sokolowski | Administrator | Facility administrator named in report header |
| Stefanie Coronel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 96
Capacity: 100
Deficiencies: 0
Apr 29, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff unlawfully evicted a resident.
Findings
The investigation reviewed records and conducted interviews regarding the eviction allegation. The evidence did not substantiate the claim, as the resident was provided a 30-day notice for nonpayment of rent and moved independently. Therefore, the allegation was unsubstantiated.
Complaint Details
The complaint alleged that staff unlawfully evicted a resident. The investigation found that the resident was given a 30-day notice due to failure to pay rent, assistance was offered but declined, and the resident moved independently. The allegation was unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 100
Census: 96
Date of 30-day notice: Oct 20, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gail Johnson | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Marili Barajas | House Manager | Interviewed regarding the eviction and facility operations |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 100
Deficiencies: 0
Mar 16, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff stole a resident's money.
Findings
The investigation found that the facility was the payee for the resident's social security funds and that signed withdrawal receipts were present. A social security investigator found no suspicious activity, and staff denied the allegation. The complaint was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff stole Resident #1's social security money and stimulus checks. The allegation was unsubstantiated after investigation including interviews with residents and staff, review of financial records, and social security inquiry.
Report Facts
Capacity: 100
Census: 78
Stimulus check amount: 600
Rejected IRS check amount: 1400
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tony Vasallo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Michael Sokolowski | Administrator | Facility administrator named in the report |
| Nirjara Acharya | Administrator | Met with during the inspection visit |
| Adam Zenou | Licensee who assisted with the initial complaint visit | |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 69
Capacity: 100
Deficiencies: 0
Feb 23, 2022
Visit Reason
The visit was an unannounced required one-year inspection to evaluate the facility's compliance with regulations, including infection control, physical plant, medication review, and staff and resident records.
Findings
The facility was found to be in compliance with Title 22 Regulations with no deficiencies observed. The physical plant, infection control procedures, medication storage and documentation, and staff and resident records were all satisfactory.
Report Facts
Residents reviewed: 7
Staff reviewed: 5
Hospice residents approved: 30
Bedridden residents allowed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nune Margaryan | Licensing Program Analyst | Conducted the inspection and authored the report |
| Michael Sokolowski | Administrator | Facility Administrator present during inspection |
| Marili Barajas | Office Manager | Facility Office Manager present during inspection |
| Adam Zenou | Licensee | Facility Licensee present during inspection |
| Nirjara Acharya | Administrator | Facility Administrator who assisted with the visit |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 100
Deficiencies: 0
Dec 13, 2021
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that staff did not provide a refund to a resident after moving out of the facility.
Findings
The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur, resulting in the allegation being unsubstantiated.
Complaint Details
The complaint alleged that Resident #1 was not provided a refund after moving out on 10/17/21 despite being verbally promised a pro-rated refund by staff. The resident did not provide a 30-day notice as required by the admission agreement. The allegation was unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 100
Census: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tony Vasallo | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Sokolowski | Administrator | Facility administrator named in the report header |
| Adam Zenou | Licensee met during the investigation |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 100
Deficiencies: 0
Oct 19, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted to examine the allegation of a suspicious death at the facility.
Findings
The investigation found no evidence of a suspicious death or murder at Burbank Retirement Villa East. The allegation was determined to be unfounded and dismissed.
Complaint Details
The complaint alleged a suspicious death at the facility. After interviews with staff and residents, the allegation was found to be false and without reasonable basis, resulting in an unfounded determination.
Report Facts
Capacity: 100
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joe Katrdzhyan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Michael Sokolowski | Administrator | Facility administrator involved in the investigation |
| William Boles | Administrator | Assisted with the visit |
| Wei Siew Ho | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 100
Deficiencies: 0
Oct 18, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-10-12 regarding resident care issues at Burbank Retirement Villa East.
Findings
The investigation included interviews with staff and residents and review of documentation. The allegations concerning residents not attending scheduled appointments, unmet grooming needs, unaddressed changes in medical condition, and uncomfortable environment were not corroborated by staff or resident interviews. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint included allegations that residents did not attend scheduled appointments, grooming needs were unmet, staff did not address changes in medical condition, and staff did not provide a comfortable environment. After investigation, these allegations were found to be unsubstantiated.
Report Facts
Capacity: 100
Census: 68
Number of interviewed residents: 6
Number of interviewed staff: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the complaint investigation visit |
| Michael Sokolowski | Facility Administrator | Facility Administrator present during the investigation and exit interview |
| Christine Yee | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 100
Deficiencies: 1
Oct 1, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit to gather information regarding multiple allegations including medication administration, medication logs, food service, dietary needs, facility cleanliness, and response to call buttons.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes. This requirement is not met as evidenced by incidents where staff did not respond to resident call switches in a timely manner. | Type A |
Report Facts
Capacity: 100
Census: 70
Deficiencies cited: 1
Plan of Correction Due Date: Oct 2, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kruz Long | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Fernando Fierros | Licensing Program Manager | Oversaw the complaint investigation |
| Marili Barajas | House Manager | Facility staff member interviewed during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 100
Deficiencies: 0
Sep 20, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff did not address a resident's hygiene needs and that a resident had not been properly fed while in care.
Findings
The investigation included interviews with staff and residents, and review of relevant documentation. Staff and resident interviews did not corroborate the allegations, and the investigation concluded that there was insufficient evidence to substantiate the complaints, resulting in an unsubstantiated finding.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not addressing a resident's hygiene needs and improper feeding of a resident. Interviews with four staff members and six residents indicated hygiene needs and feeding were properly addressed, with no complaints received. Five out of six residents confirmed their hygiene and feeding needs were met. One resident preferred a particular staff member for hygiene assistance but was able to manage independently if that staff was unavailable. The evidence did not support the allegations.
Report Facts
Capacity: 100
Census: 69
Number of staff interviewed: 4
Number of residents interviewed: 6
Number of allegations: 2
Residents confirming hygiene needs met: 5
Residents confirming proper feeding: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Sokolowski | Facility Administrator | Met with Licensing Program Analyst during investigation |
| Christine Yee | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 72
Capacity: 100
Deficiencies: 0
Aug 25, 2021
Visit Reason
Licensing Program Analyst Angelica Rea conducted an unannounced visit for the purpose of conducting the Required annual inspection.
Findings
The inspection found no deficiencies. The facility was observed to have required furniture, clean bathrooms with grab bars, unobstructed passageways and exits, operational smoke detectors, and proper infection control practices.
Report Facts
Hot water temperature: 113.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the inspection and discussed infection control practices |
| William Boles | Administrator | Facility administrator present during inspection |
| Marili Barajas | Office Manager | Assisted with the inspection visit |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 100
Deficiencies: 0
Aug 25, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 07/30/2021 regarding allegations of damaged wheelchair, lack of accommodations, withholding of medical records, and failure to safeguard resident's personal belongings.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with staff, residents, and the administrator, as well as facility observations, indicated that wheelchairs were not damaged, accommodations were provided, medical records were being arranged for release, and personal belongings were safeguarded.
Complaint Details
The complaint involved four allegations: damaged wheelchair, lack of accommodations, withholding medical records, and failure to safeguard personal belongings. The investigation was unsubstantiated due to insufficient evidence to prove violations.
Report Facts
Capacity: 100
Census: 72
Residents interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation and issued final results |
| William Boles | Administrator | Met with Licensing Program Analyst during investigation and assisted with the visit |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 100
Deficiencies: 0
Jul 16, 2021
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that the facility financially abused a resident by stealing the resident's identity, opening a bank account in the resident's name, and misappropriating social security income and a money order.
Findings
Interviews and records review revealed that the resident had authorized automatic deposit transfers for care costs, and the resident was officially discharged prior to the investigation. The administrator denied stealing the money order, and the resident could not provide details to support the allegation. Based on the information obtained, the allegations of financial abuse were unsubstantiated.
Complaint Details
The complaint alleged financial abuse of a resident, including identity theft, unauthorized bank account creation, and theft of a $500 money order. The investigation found no substantiation for these allegations.
Report Facts
Capacity: 100
Census: 69
Money order amount: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendell Smith | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jill Nakata | Licensing Program Manager | Named as Licensing Program Manager on report |
| Michael Sokolowski | Administrator | Facility administrator involved in investigation |
| Bill Boles | Met with Licensing Program Analyst during visit |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 100
Deficiencies: 0
Jun 7, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff financially abused a resident.
Findings
The investigation included interviews with staff and residents, and review of relevant documentation. No evidence was found to substantiate the allegation of financial abuse by staff. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged staff financially abused a resident. Interviews with the Office Manager, staff, and residents indicated that the Office Manager handles residents' monies and there were no complaints or concerns about financial abuse. Four out of five residents interviewed denied witnessing any financial abuse. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Capacity: 100
Census: 65
Residents receiving assistance with money handling: 5
Residents interviewed: 4
Residents not interviewed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Sokolowski | Facility Administrator | Former Facility Administrator mentioned in investigation |
| William Boles | Facility Administrator met during the visit | |
| Marili Barajas | Office Manager | Interviewed during the investigation regarding financial handling |
| Christine Yee | Licensing Program Manager | Named in report signature |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 100
Deficiencies: 0
Jun 7, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations regarding medication administration, medication disposal, and accuracy of medication logs at the facility.
Findings
The investigation found no corroboration for the allegations. Staff and resident interviews indicated medications were administered as prescribed, disposed of properly, and medication logs were accurate and up-to-date. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was triggered by allegations that residents were not administered medication as prescribed, staff disposed of residents' medication improperly, and staff were not keeping accurate medication logs. The investigation included interviews with staff and residents and review of documentation. The allegations were found to be unsubstantiated.
Report Facts
Capacity: 100
Census: 65
Number of interviewed residents: 6
Number of interviewed staff: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Sokolowski | Facility Administrator | Named in the report as former administrator; no longer working at the facility |
| William Boles | Facility Administrator | Met with Licensing Program Analyst during investigation |
| Marili Barajas | Office Manager | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 100
Deficiencies: 1
Jun 2, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-05-25 regarding refusal to provide resident medical records, lack of privacy during diaper changes, and staff yelling at residents.
Findings
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 raised her voice at residents.
Complaint Details
The complaint investigation was initiated based on allegations that the facility refused to provide a former resident's medical records, residents were not accorded privacy during diaper changes, and staff yelled at residents. The refusal to provide records and privacy allegations were unsubstantiated, while the staff yelling allegation was substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by staff yelling at residents. | Type A |
Report Facts
Capacity: 100
Census: 64
Deficiencies cited: 1
Plan of Correction Due Date: Jun 3, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Boles | Administrator | Met with Licensing Program Analysts during investigation and discussed allegations |
| David Sicairos | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Rebecca Orendain | Licensing Program Manager | Oversaw complaint investigation |
| Staff #1 | Identified as staff member who yelled at residents, substantiated allegation |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 100
Deficiencies: 0
May 7, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that a resident fell while in care resulting in a fracture.
Findings
The investigation found that the resident had an unwitnessed fall resulting in a hip fracture. Staff and resident interviews indicated no neglect or lack of supervision. The allegation was determined to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that a resident fell from a wheelchair and sustained a hip fracture. The investigation included interviews with staff, residents, and review of medical reports. The allegation was unsubstantiated.
Report Facts
Capacity: 100
Census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Lisa Hicks | Licensing Program Manager | Named in report as Licensing Program Manager |
| William Boles | Administrator | Facility Administrator interviewed during investigation |
| Michael Sokolowski | Administrator | Facility Administrator named in report header |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 100
Deficiencies: 1
Apr 18, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including the presence of bed bugs and staff not treating residents with dignity and respect.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87303 (a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by the presence of german roaches and bed bugs in the facility, with exterminator services limited to only some rooms. | Type B |
Report Facts
Facility capacity: 100
Census: 64
Plan of Correction Due Date: May 18, 2021
Pest control service dates: Jan 29, 2021
Pest control service dates: Mar 3, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda M Almaraz | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Michael Sokolowski | Administrator | Facility administrator involved in the investigation |
| William Boles | Administrator | Met with Licensing Program Analyst during investigation |
| Christine Yee | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 100
Deficiencies: 0
Mar 1, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 07/15/2020 concerning staff verbally abusing and threatening a resident, and financial abuse of a resident while in care.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. The Administrator denied verbally abusing or threatening the resident and denied financial abuse. The resident expressed feeling threatened due to rent and quarantine discussions but acknowledged no actual threats. No citations were issued.
Complaint Details
The complaint involved allegations of staff verbally abusing and threatening a resident, and financial abuse of the resident. The investigation was conducted telephonically due to COVID-19. Interviews with the Administrator, staff, and resident revealed disagreements over rent payment and restrictions related to COVID-19 safety measures. The resident felt verbally threatened but the allegations were unsubstantiated.
Report Facts
Capacity: 100
Census: 54
Overpayment withholding amount: 120
Attempted withdrawal amount: 900
Overdraft fee: 25
Rent amount resident could afford: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Sokolowski | Administrator | Interviewed regarding allegations of verbal abuse, threats, and financial abuse |
| Nicol Wesley | Licensing Program Analyst | Conducted the complaint investigation |
| Marili Barajas | Office Manager | Participated in telephonic investigation and exit interview |
| Rebecca Orendain | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 100
Deficiencies: 0
Dec 24, 2020
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff did not notify the authorized representative of a resident's change in condition.
Findings
The investigation found the complaint to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis. The complaint was therefore dismissed.
Complaint Details
The complaint alleged that staff did not notify the authorized representative of a resident's change in condition. The investigation was conducted telephonically due to COVID-19 mitigation measures. Staff #1 stated that Resident #1 did not reside in the facility. The complaint was found to be unfounded.
Report Facts
Capacity: 100
Census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kruz Long | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Sokolowski | Administrator | Facility administrator named in the report |
| Adam Zenou | Licensee | Met with during the investigation and exit interview |
| Fernando Fierros | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 100
Deficiencies: 0
Nov 12, 2020
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation of illegal eviction received on 2020-11-06.
Findings
The investigation found the complaint to be unfounded after telephone interviews and document review, determining that the resident in question did not reside at the facility and was admitted to the hospital. The complaint was dismissed.
Complaint Details
The complaint was investigated and determined to be unfounded, meaning the allegation was false, could not have happened, and/or was without reasonable basis.
Report Facts
Capacity: 100
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Michael Sokolowski | Administrator | Facility administrator interviewed during investigation |
| Christine Yee | Licensing Program Manager | Named in report header |
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