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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609135
Report Date: 03/17/2022
Date Signed: 03/17/2022 02:04:03 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/17/2022 02:04 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BURBANK HILLS COMFORT LIVINGFACILITY NUMBER:
197609135
ADMINISTRATOR:HANNESYAN, NARINEFACILITY TYPE:
740
ADDRESS:2745 N MYERS STTELEPHONE:
(818) 736-5097
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 6DATE:
03/17/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Narine HannesyanTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing program analysts (LPAs) Jewel Baptiste and Noemi Galarza conducted an unannounced case management visit to reissue deficiencies and technical violations cited on 3/8/2022. LPAs was greeted by administer Narine Hannesyan and explain the reason for the visit.

Upon arrival LPAs observed broken door bell. During todays visit LPAs toured the inside and outside of the facility.LPAs observed cleaning supplies unlocked and located in the hall closet. LPAs asked administrator about physicians orders for residents, to which she stated she is still working on it. LPAs also asked for in service training for staff, and administrator stated she trained staff but she did not keep record of the training.

LPAs observed the garage is under construction and is being converted into Additional dwelling unit (ADU). Pool with required fencing was observed. The back yard is currently off limits to residents at this time. A change of operation and facility sketch will be submitted to Licensing with the updated information.

During file review on 3/8/2022 LPA observed administrator certificate expired 3/31/2021, LPA checked CDSS online database and could not find the Administrator information (active/pending). On 3/11/22 LPA contacted admincertinfo@dss.ca.gov and they stated that they have not received anything from the administrator and the absence from the active/pending list is aligned with not having received a renewal application from the administrator for the 2021-2023 year. A technical violation was given on 3/8/22, LPAs will reissue citation with a type B violation.

Report continued on 809c

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135
VISIT DATE: 03/17/2022
NARRATIVE
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On 3/8/22 Staff#3 did not have criminal record clearance and was not associated to the facility. Per administrator Staff 3 has been living at the facility for three days. Staff left the facility during the visit. As of 3/17/22 S3 has been associated to the facility LPA issued type A violation and did not assess civil penalties at the time of the visit. LPA will reissue citation with civil penalties.

During visit on 3/8/22 LPA Baptiste observed that all facility employee’s CPR card was expired. LPA issued a technical violation. LPA will reissue as a type B citation. On todays visit administrator showed proof of having CPR certification.

During client file review on 3/8/22 LPA Baptiste observed Resident #1 file was missing pre-appraisal, needs and service and functionality capabilities form. Resident #2 physician report was blank, pre-appraisal, needs and service, and capability and functional form was missing. A technical violation was given on 3/8/22 and LPAs will reissue to type B citations.

During medication review for residents#1 and #2 there was no physicians’ orders. LPA could not review medications. When LPA asked administrator how they administer medications to residents, she stated “we just read the bottle”. During today's visit, administrator has not obtained residents physicians orders. LPA will issue a type A citation.

On 3/8/22, LPA Baptiste was informed by administrator Hannenesyan that the garage is being converted to a bedroom. LPA asked for a building permit and for Licensee to submit change of operation documents by 3/11/22. Administrator did not submit and or return phone calls. Due to technical problems on 3/8/22 LPA could not finish report to add information about garage. LPA was able to obtain a copy of the permit from city planning but has not received change of operation documents from Licensee. LPA will issue a type B citation.

Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with administrator / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
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Document Has Been Signed on 03/17/2022 02:04 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 03/17/2022 at 10:41 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2022
Section Cited
CCR
87465(e)

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Incidential Medical & Dental Care: For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all the following information
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Administrator will ensure each resident has a copy of their completed physicians’ orders. Administrator understands that it is their responsibility to make sure each resident has physicians’ orders with their medications.

Submit a copy of residents (R1-R3) physician orders by 3/18/22.
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This requirement is not met by evidence of: Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents did not have physicians’ orders in resident files, which poses an immediate health, safety, or personal rights risk to persons in care.
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Type A
03/18/2022
Section Cited
CCR87355(e)(1)

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87355 Crimanal Record Clearance(e)
All individuals subject to a criminal record review pursant to Health and safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the department or
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On 3/8/2022, staff (S3) immediately left the facility.Administrator acknowledged understanding that staff shall not return to work until criminal record clearance and association is complete. associated to the facility before S3 returns. Staff (S3) was cleared and associated to the facility on 3/10/22
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This requirement is not met by evidence by: Based on record review on 3/8/2022, the licensee did not comply with the section cited above in 1 out of 1 Staff is not fingerprinted, associated or have background check clearance, which poses an immediate health, safety, or personal rights risk to persons in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


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Document Has Been Signed on 03/17/2022 02:04 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 03/17/2022 at 10:51 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2022
Section Cited
CCR
87412(d)

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87412 Personnel Records: The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

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Administrator will submit the required document to Sacramento and pay the necessary fees to renew certification.

A copy of new administrator certification is due to licensing by POC date.
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This requirement is not met by evidence by: Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff Administrator Certification expired 3/31/21.
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Type B
03/30/2022
Section Cited
CCR87458(a)

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87458 Medical Assessment:Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
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Administrator will ensure residents files will be updated with a completed physician’s report signed by the doctor.

Submit a copy of residents (R1-R3) physicians report by POC date
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This requirement is not met by evidence by: Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents physicians report was blank and not update, which poses an immediate health, safety, or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


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Document Has Been Signed on 03/17/2022 02:04 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 03/17/2022 at 10:56 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2022
Section Cited
CCR
87457(c)(1)(A)

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Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. The appraisal shall include, at a minimum, an evaluation of the 87457 Pre admission Appraisal- General: prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors. The licensee shall be permitted to use the form LIC 603 (Rev. 6/87), Preplacement Appraisal Information, to document the appraisal.
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Administrator will ensure residents files will be updated with a completed pre appraisal and functional capabilities assessment in every residents file. Documents to be updated by 3/24/22.

Submit a copy of residents (R1-R3) pre admission apprisal and functional capabilities assessment by POC date.
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This requirement is not met by evidence by: Based on record review, the licensee did not comply with the section cited above in 3 out of 3 residents did not have preplacement appraisal and functional capacities in resident files, which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
03/24/2022
Section Cited
CCR87208(a)

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87208- Plan of Operation:Each facility shall have and maintain a current, written definitive plan of operation. 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:
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Based on observed, the licensee did not comply with the section cited above in Licensee did not inform CCLD and submitted a change of operation, which poses an immediate health, safety, or personal rights risk to persons in care.

Administrator will update and submit a copy of facility sketch and change of operations by POC date.
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This requirement is not met by evidence by: Administrator will ensure to submit a change of operation to CCLD and review regulation 87208(a) to ensure compliance in the future.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


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Document Has Been Signed on 03/17/2022 02:04 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 03/17/2022 at 11:01 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2022
Section Cited
CCR
87412(a)

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87412 Personnel Records:The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information:
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Administrator will ensure each Staff record will have a copy of their employee rights by 3/24/22.

Administartor will update staff file and submit a copy to Licensing by POC.
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This requirement is not met by evidence by: Based- on record review, the licensee did not comply with the section cited above in 2 out of 2 Staff employee rights was not in their files, which poses an immediate health, safety, or personal rights risk to persons in care.
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Type B
03/24/2022
Section Cited
CCR87707(a)(2)(A)

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87707 Training Requirments: Direct care staff shall complete at least eight hours of in-service training about serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period. Direct care staff hired as of July 3, 2004 shall complete the eight hours of in-service training within 12 months of that date and in each succeeding 12-month period. A minimum of two of the following training topics shall be covered annually, and all topics shall be covered within a three-year period…

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Administrator will make sure to keep record of all staff training.

Submit a copy of staff in service training by POC date.
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This requirement is not met by evidence by: During record review on 3/8/22 and todays visit LPAs observe no staff training.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 03/17/2022 02:04 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 03/17/2022 at 11:56 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2022
Section Cited
CCR
87705

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The following shall be stored inaccessible to residents with dementia:Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Administrator will ensure disinfectants and cleaning supplies are locked at all times.


Administrator removed disinfectants and cleaning supplies during the visit. Corrected during the visit
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This requirement is not met by evidence by: During LPAs tour facility staff had left cleaning supplies in hall closet.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


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