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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609490
Report Date: 03/10/2022
Date Signed: 03/10/2022 02:48:03 PM

Document Has Been Signed on 03/10/2022 02:48 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 VILLA INCFACILITY NUMBER:
197609490
ADMINISTRATOR:SARKISYAN, SEROPFACILITY TYPE:
740
ADDRESS:2324 REESE PLTELEPHONE:
(323) 610-0000
CITY:LOS ANGELESSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 3DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Serop Sarkisyan, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA knocked at the door for 10 minutes; there was no answer. Licensee was called and Assistant Administrator Administrator Johnny Sarkisyan arrived shortly after. Administrator Serop Sarkisyan also arrived shortly after. There are three (3) level 4 developmentally disabled clients over the age of 60. The facility is serviced by Lanterman Regional Center. The facility is a single story home located in a residential neighborhood that is licensed for 6 non-ambulatory clients. A hospice waiver for 3 residents is in place. It consists of 6 bedrooms, 2 bathrooms, living room/dining area, kitchen with laundry area, outdoor covered patio, and detached garage. The last fire drill was conducted on 3/5/2022.

The following were observed/inspected:
  • COVID-19 Infection Control screening and signs were observed in the entrance, common areas, hallways, and bathrooms. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Facility has an approved COVID-19 Mitigation Plan.
  • Each resident room has been designated as a COVID-19 solation room if needed.
  • Three (3) centrally stored resident medication records were reviewed.
  • Staff was observed wearing a surgical mask.
  • Clients in care do not wear masks because they lack hazard awareness and impulse control.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Insect poison control bottles were observed unlocked in the rear patio area. The detergent cabinet was also unlocked.
NOTE: Technical advisory- Licensee was advised to install a door bell at the front door. Staff did not hear LPAs door knocks during today's visit.
Deficiency was cited.
Exit interview was conducted with Administrator Serop Sarkisyan. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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Document Has Been Signed on 03/10/2022 02:48 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/10/2022 at 02:19 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BURBANK VILLA INC
FACILITY NUMBER: 197609490

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that insect poison control bottles were observed unlocked in the rear patio area, and the detergent cabinet in the laundry area was also unlocked,]which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2022
Plan of Correction
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**CLEARED- The insect poison and detergents were locked during the visit.
Licensee shall conduct staff training.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
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