Inspection Reports for
Savant of Burbank East

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.

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.

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

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

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

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

The complaint was substantiated. It 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.

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.

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

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

The complaint alleged that 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 investigation found that staff cut the resident's hair without consent or notifying the resident's Power of Attorney, and failed to update the resident's service plan. The allegation was substantiated.

The allegation was substantiated based on interviews with staff, residents, and review of records. It was found that staff cut the resident's hair without family permission, violating the resident's personal rights and posing an immediate health and safety risk.

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

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

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

The allegation of questionable death was substantiated due to the facility's failure to keep the rooftop locked, which allowed the resident access resulting in hospitalization and eventual death. Other allegations including financial abuse, failure to prevent harm by another resident, and failure to provide a safe environment were investigated and deemed unsubstantiated.

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

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

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

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

The complaint was substantiated. Allegations included hospitalization due to staff neglect, development of pressure injuries, inadequate food and liquid intake. The resident was found unresponsive and hospitalized with diagnoses including septic shock, dehydration, malnutrition, and stage 2 pressure injuries likely due to lack of turning and care.

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 properly observe and document changes in the resident's condition and did not ensure timely medical intervention.

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

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

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

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