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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603137
Report Date: 04/08/2025
Date Signed: 04/08/2025 04:23:41 PM

Document Has Been Signed on 04/08/2025 04:23 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:SAVANT OF BURBANK WESTFACILITY NUMBER:
198603137
ADMINISTRATOR/
DIRECTOR:		VALDEZ, SILVIAFACILITY TYPE:
740
ADDRESS:1911 GRISMER AVETELEPHONE:
(818) 295-2727
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 100CENSUS: 92DATE:
04/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Silvia Valdez - Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 04/08/25, 9:00 am Licensing Program Analysts (LPAs) Nadia Shahbazian and Evelin Rios conducted an unannounced required annual inspection. LPAs met with Executive Director, Silvia Valdez and explained the reason for the visit. Facility is licensed as a two-story building. Fire clearance approved for one hundred (100) non-ambulatory residents; ten (10) of whom may be bedridden. Hospice waiver is approved for thirty (30) residents.

LPAs requested copies of the resident roster, Personnel Report (LIC 500), nine (9) randomly selected resident records and seven (7) staff files. At approximately 10:00 am, LPAs reviewed seven (7) randomly selected staff files for completeness, LPAs observed the files to be complete with updated training records.

From 12:00 pm to 1:20 pm, LPAs along with the Executive Director conducted a tour of the physical plant. During the tour, LPAs interviewed six (6) residents and four (4) staff. During the physical plant tour LPAs observed the following:

The Screening/Reception area is located immediately upon entrance. Required postings were displayed at the reception area. Facility’s main door is the primary entry/exit access. The facility has five (5) delayed egress exit doors. LPA tested one of the delayed egress doors on the first floor and observed it to function properly. Facility has one elevator. LPAs observed an evacuation chair atop of one (1) of the three (3) stairwells.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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: SAVANT OF BURBANK WEST
FACILITY NUMBER: 198603137
VISIT DATE: 04/08/2025
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Common areas: First floor has a dining room, lobby/television room, outside and an inside patio areas. Second floor has an activity room. Common areas observed to be clean and furnishings observed to be in good condition. No obstructions or hazards were observed. Carbon monoxide detectors were observed on the first floor and were functional. Fire extinguishers are located all throughout the facility and last inspected on 04/01/2025. The facility is equipped with cameras in common areas and a sprinkler system.

Kitchen: Facility’s kitchen was observed to be clean, sanitary, and inaccessible to residents. LPAs observed an adequate supply of perishable foods for two (2) days, and non-perishable food supply for seven (7) days, which were located in the refrigerator, freezer, and pantry. Food was properly labeled and stored. Emergency food is stored in a separate walk-in pantry. Sharps are stored in the kitchen; inaccessible to residents. LPAs observed records of special dietary needs and weekly menu in the kitchen.

Medications were kept in locked medication carts in the medication room, inaccessible to residents. LPA observed complete first aid kits and first aid manual in the medication room. At 1:25 p.m., medications and medication records for ten (10) residents were reviewed by LPA Shahbazian with the assistance of the Regional Director, Lisa Pham.



Facility Disaster drill was last conducted on 03/25/2025. Fire protection equipment were last inspected by Delta Fire Equipment, INC on 05/13/2024. Review of records indicate facility passed the annual fire inspection. LPA Rios reviewed the facility's liability insurance, infection control plan, and disaster plan. Records were complete and up-to-date.

Due to time constraints, LPAs were unable to complete today's annual inspection. LPAs will complete the inspection at a later date. Exit interview conducted. Copy of report provided to Executive Director.
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
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