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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607065
Report Date: 07/29/2025
Date Signed: 07/29/2025 05:36:48 PM

Document Has Been Signed on 07/29/2025 05:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BURBANK HILLS RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197607065
ADMINISTRATOR/
DIRECTOR:		DINA ALGERFACILITY TYPE:
740
ADDRESS:425 UNIVERSITY AVENUETELEPHONE:
(818) 588-3122
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 4DATE:
07/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:DIna Alger-TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analysts (LPA), Nadia Shabazian, conducted an unannounced annual inspection at the facility mentioned above. LPA met with Dominor Viernes-Caregiver and explained the reason for the visit. LPA spoke with Dina Alger - Administrator, over the telephone, who stated that she has a scheduled medical procedure and is unable to come. Administrator designated Dominor Viernes to sign the report. At approximately 1:20 pm, Administrator-Dina Alger entered the facility and met with LPA.

The facility is approved for six (6) non-ambulatory residents, all of whom may be bedridden. Facility's hospice approval was increased to total of six (6) residents. Current census is four (4).

At 9:40 am, LPA conducted a physical tour, with the assistance of staff and observed the following:

Required postings were observed in the living room and dining room walls. The smoke/carbon monoxide detectors are hardwired and interconnected. At 10:20 am, the smoke/carbon monoxide detectors were tested and functioned properly. There are five (5) fire extinguishers located in the kitchen, front entry, hallway, patio and in the converted garage. All the fire extinguishers were fully charged on 08/01/2024.



Kitchen: Appliances consisted of stove, dishwasher, microwave and refrigerator. LPA checks all the appliances for cleanliness and observed them to be clean and operational. All knives and sharps observed to be locked in a kitchen drawer and chemicals were locked underneath the sink, inaccessible to residents. The cabinets were supplied with plenty of non-perishable foods, for minimum of 1 week; and refrigerator was supplied with perishable foods for 2 days. There were plenty of dishes maintained in the kitchen cabinets. Thee kitchen has a door, leading to the laundry room. LPA observed laundry detergents and chemicals in locked cabinets. The laundry machines included one washer and one dryer, which were in functional mode. There is an exit door in the laundry room, which leads to the backyard.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BURBANK HILLS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197607065
VISIT DATE: 07/29/2025
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Common Areas: According to the facility sketch, the common areas included a family room, the living room and dining room. Based on the sketch, the living room is located by the entry door; the dining room is near the kitchen and the family room is a large space, also next to the kitchen. LPA observed that the licensee has repurposed the facility living room as living quarters for the licensee and family. The dining room is currently being used as the office/music room. The large family room is being used currently as a dining room and living room. The common areas were properly furnished with sofas and dining room chairs and table, appropriate for number of residents. In addition, living room was furnished with book cases and cabinets for gaming/entertainment. There are three storage cabinets for linens and supplies, one in the living room and two in the hallway. Facility is equipped with cable, internet and land line and cameras in front and back/side yard areas.

Bedrooms: There are three (3) bedrooms for resident use. All bedrooms are shared but currently bedroom #2 is used as a private bedroom. Bedroom #3 has an exit door, leading to the backyard. All bedrooms were clean, properly furnished with dresser drawers, closets, chairs with ample lighting and bedding for the residents.

Bathrooms: There are three (3) bathrooms, one (1) designated for residents' use, one (1) for the staff and one half (1/2) bathroom in the backyard patio/garage area. Both bathrooms in the house were properly supplied with paper towels, tissues and hand soap, and had functional fixtures (grab bars and non-skit mats). Hot water temperature was measured at 112.4 degrees Fahrenheit.

Surrounding Grounds: There is a covered patio with furniture appropriate for outdoor use, for the number of residents. The outdoor area was free of hazards. There are two side exits in the backyard, but facility uses the entry door as the main exit. There is no body of water present. The garage is currently being used as storage/sleeping quarter for staff. There is also a half (1/2) bathroom outside of the garage/staff room.

(Continued on 809-C)
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BURBANK HILLS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197607065
VISIT DATE: 07/29/2025
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Medications: LPA observed all medications and Medication Administration Records (MARs) in a locked kitchen cabinet. A complete First Aid kit and the First Aid Manual was also observed.

Resident records: All records were observed as locked and inaccessible to residents. Records for four (4) out of four (4) residents were reviewed for resident rights, physician reports, admission agreements and additional documents. Resident records appeared to be complete and current.

Staff records: All records were observed as locked in the office area. A total of three (3) staff files were reviewed. Criminal record clearances were present, and staff are associated to this facility. Staff records appear to be complete and current.

The Administrator admitted that ever since the Covid-19 Pandemic, licensee has been using the living room as living quarters for the family, without submitting any plan of approval from CCLD or submitting updated sketches. In addition the garage is also being used as temporary staff room, without prior approval from CCLD. Licensee will obtain permits, current sketch and fire inspection report for the garage and converted living/diring rooms and will submit them to CCLD within 30 days.

Based on initial Plan of Operations submitted, the licensee will ensure that there are sufficient number of staff scheduled to work all shifts. Based on Title 22 Regulation: A new Plan of Operations and LIC 500 (Personnel Report) shall be submitted to CCLD within thirty (30) days, to ensure sufficient staff coverage during a 24 hour shift.

Deficiencies cited during today’s visit. Appeal rights issued and given.

Exit interview conducted and a copy of this report was given to facility Administrator.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2025 05:36 PM - It Cannot Be Edited


Created By: Nadia Shahbazian On 07/29/2025 at 04:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BURBANK HILLS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197607065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above to ensure that facility is staffed with sufficient number of staff to cover all operational shifts, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee will submit a Plan of Operation and LIC 500 (Personnel Report) to CCLD by the POC date. Licensee will maintain and operate the facility in accordance to the terms specified in the plan of action.
Type B
Section Cited
CCR
87305(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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87305 Alterations to Existing Building or New Facilities.
Based on observation and interview, the licensee did not comply with the section cited above to notify CCLD and to submit necessary permits for facility alterations, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee will submit in writing, an inspection report from the Burbank Fire Department, along with a new sketch of the garage and/or facility alterations, by the POC date. Licensee will ensure to communicate with CCLD any future changes and to obtain approval, prior to commencing.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Eva Miller
NAME OF LICENSING PROGRAM MANAGER:
Nadia Shahbazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
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