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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 04/09/2025
Date Signed: 04/09/2025 03:45:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2024 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20241017131331
FACILITY NAME:SAVANT OF BURBANK EASTFACILITY NUMBER:
198603136
ADMINISTRATOR:ACHARYA, NIRJARAFACILITY TYPE:
740
ADDRESS:1900 GRISMER AVETELEPHONE:
(818) 843-3141
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 94DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Imelda Villanueva- Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Insufficient supervision contributed to residents sustaining injuries.
INVESTIGATION FINDINGS:
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On 04/09/2025 Licensing Program Analysts (LPA) Evelin Rios and Nadia Shahbazian conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegation. LPAs met with Imedla Villanueva, Executive Director and explained the reason for today’s visit. Executive Director placed Nirjara Acharya, Vice President of Operations and Lisa Pham the Regional Director on speaker phone to listen to report.

On 10/17/24, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator, Jose Santana.


(Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20241017131331
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAVANT OF BURBANK EAST
FACILITY NUMBER: 198603136
VISIT DATE: 04/09/2025
NARRATIVE
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(Continued from LIC9099)
On 10/23/2024 at 10:20 a.m., LPA Evelin Rios initiated the complaint visit. LPA Rios conducted physical plant tour and obtained copies of the facility records such as, Personnel Report, Training Records, Unusual Incident/Injury Reports (UIRs), Preplacement Appraisal Information, Physician’s Report, Function Report, and Face Sheet. LPAs, Evelin Rios and Abeye Duguma conducted interviews with residents. On 10/23/2024 LPAs, Evelin Rios and Abeye Duguma conducted interviews with residents. Regarding the allegation that due to insufficient supervision contributed to residents sustaining injuries, it was alleged that resident #1 (R1) had multiple falls in the facility and had at least on one occasion had been on the floor for hours. Documentation such as but not limited to, Unusual Incident Reports obtained in the facility describe R1 as having multiple falls on 10/14/2024 and 10/15/2024 including on or around 5/04/2024, 7/08/2024, 9/01/2024, and 10/10/2024 resulting in R1's hospitalization While the facility, responded to R1’s falls on 5/04/2024 and 9/01/2024 by arranging for physical therapy and rehabilitation, the facility retained R1 despite knowing R1 required a higher level of care. Facility staff instead instructed R1 to activate their bedroom pull cord whenever requiring toileting assistance. On 9/20/2024, R1’s primary care physician’s office advised the facility that R1 might need to transfer to a skilled nursing facility (SNF) due to R1’s need for “constant monitoring,” but the facility retained R1 for almost another month, during which R1 sustained at least five falls. IB investigator Jose Santana’s interview with the facility’s Administrator, Imelda Villanueva justified retaining R1 because she said arrangements were already in process, as early as August 2024, to relocate R1 to a SNF. Villanueva also admitted that in the interim, the facility was not able to meet R1’s needs. The facility did not consider providing a one-on-one caregiver or obtaining a fall mat, motion sensor, or bed alarm for his safety until the time R1 could relocate. Based on the information gathered during the investigation, the allegation is deemed Substantiated at this time.

An immediate civil penalty (See LIC 421C/Civil Penalty Assessment-Immediate) of $500.00 was assessed on this day of the visit for violations that resulted in injury wherein the facility failed to provide the necessary care for R1. If the Department determines that the underlying violation resulted in serious bodily injury, the licensee will be notified that an increase of civil penalties will be assessed based on Health and Safety Code §1569.49(f). Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241017131331
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SAVANT OF BURBANK EAST
FACILITY NUMBER: 198603136
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2025
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:
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R1 is no longer in the facility.
1. Administrator will submit a statment of understanding on the cited regulation and provide a copy to CCLD by POC due date 04/01/25.
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Based on IB interviews and R1’s records review, the licensee-administrator failed to ensure that R1 was properly supervised which resulted in R1 sustaining serious injuries from multiple falls which posed an immediate health and safety and personal rights risk to resident in care.
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2. Administrator states an all staff in-service training regarding supervising residents has been conducted. Sign-in sheets and training topics will be provided by POC due date 04/01/25.
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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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3