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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 11/20/2024
Date Signed: 11/20/2024 02:38:35 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/18/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20241118083437
FACILITY NAME:SAVANT OF BURBANK WESTFACILITY NUMBER:
198603137
ADMINISTRATOR:VALDEZ, SILVIAFACILITY TYPE:
740
ADDRESS:1911 GRISMER AVETELEPHONE:
(818) 295-2727
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 94DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Silvia ValdezTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff are not providing resident with oxygen resulting in hospitalization.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with Executive Director, Silvia Valdez, and explained the reason for the visit.

--- Staff are not providing resident with oxygen resulting in hospitalization.

It was alleged that caregivers are unable to provide oxygen to Resident #1 (R1) due to scope of practice limits resulting in hospitalization. To investigate the allegation, at around 11:00a.m., LPA requested pertinent documents and interviewed staff from 11:30a.m. to 12:30p.m. A review of R1’s hospice services and facility Hospital Log revealed that Resident #1 (R1) was put on oxygen after initiation of hospice services on 11/14/2024 and has not been hospitalized since for lack of oxygen or otherwise.

(CONT. on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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 2
Control Number 31-AS-20241118083437
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAVANT OF BURBANK WEST
FACILITY NUMBER: 198603137
VISIT DATE: 11/20/2024
NARRATIVE
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During interviews with staff, Staff #1 (S1) and Staff #2 (S2) stated all residents using oxygen in the facility are receiving hospice services and all oxygen administration in the facility is performed by their respective hospice agency nurses. Staff added if they see a change in condition, they immediately contact the hospice agency, and an appropriately skilled professional is dispatched.

Based on record review and interview, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2