198603412-5-12-2026-31-AS-MGFS-DV6RA9-20260618125043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603412
Report Date: 05/12/2026
Date Signed: 05/12/2026 04:31:39 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
09/15/2025 and conducted by Evaluator Nadia Shahbazian

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250915150444

FACILITY NAME:	GRANT SERENITY HOMES OF BURBANK, INC		FACILITY NUMBER:	198603412
ADMINISTRATOR:	MARTIN ADJIAN		FACILITY TYPE:	740
ADDRESS:	436 N. REESE PLACE		TELEPHONE:	(818) 425-6797
CITY:	BURBANK	STATE: CA	ZIP CODE:	91506
CAPACITY:	6	CENSUS: 3	DATE:	05/12/2026
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Hasmik Mheryan-Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident went AWOL while in care of staff resulting in nasal fractures and multiple injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nadia Shahbazian arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Administrator – Hasmik Mheryan. LPA explained the purpose of this visit is to deliver findings for the above allegation.

On 09/16/25, LPA Shahbazian initiated a complaint investigation and conducted a health and safety check of the facility and requested copies of staff roster, resident roster and documents pertaining Resident 1 (R1). No health and safety concerns were observed during the visit on 09/16/25. On 10/12/25, 10/13/25, 10/23/25, and 11/12/25 the Department’s representative conducted interviews with staff, R1’s responsible party, and/or residents. On 10/30/25 the Department’s representative requested medical records.

On 05/12/26 LPA Shahbazian condcuted a physical thour, no health and safety concerns were observed. LPA delivered findings for the above allegation.

Continued 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

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-20250915150444

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GRANT SERENITY HOMES OF BURBANK, INC	FACILITY NUMBER: 198603412
	VISIT DATE: 05/12/2026

NARRATIVE

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Regarding allegation: Resident went AWOL while in care of staff resulting in nasal fracture and multiple injuries. It Is alleged that on 09/13/25 Resident #1 (R1) left the facility unattended, sustained a fall that resulted in a nasal fracture and bruises, subsequently being hospitalized.

The investigation revealed the following: Interview conducted with Licensee revealed, licensee was called by Burbank Police Department and was notified that R1 was found and had gone missing from the facility. A caregiver from a registry agency was brought in to cover the shift. Based on interview with registry staff on 11/13/25, they stated they were not aware that the door alarm was not on. Caregiving agency staff stated they assisted R1 to sit in the living room as they assisted other residents and did not know R1 had walked out of the facility. When caregiving agency staff looked for R1 inside and outside the facility for 15 minutes, they received a phone call from the Fire Department, notifying them of R1’s hospitalization. Per caregiving agency staff, it was the responsibility of the previous shift staff to set the door alarm because caregiving agency staff did not know how to operate them.

Per documents reviewed Physician’s report dated: 10/02/23 notes of dementia for R1. Incident report (SIR) dated: 9/14/25 submitted to the Department notes that on 09/13/25, a Caregiving Agency staff was called to provide care during the night shift, as facility’s evening shift staff had called out sick. SIR also notes, R1 had walked a distance from the facility and fell. A neighbor called 911, and R1 was taken to the hospital. Per Hospital Admissions Record dated: 09/13/25, R1 was admitted to the hospital on 09/13/25 after R1 sustained a ground level fall and was brought in by Emergency Responders (EMS). R1 was admitted to the hospital with an open fracture of nasal bone. Based on the information obtained, a Caregiving agency staff was covering the night shift on 09/13/25, during this shift R1 left the facility unattended, sustained a fall that resulted in an open nasal bone fracture. Therefore, the allegation is substantiated.

Based on interviews and review of records obtained, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8, are being cited on the attached LIC 9099D.

***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining an open nasal fracture while in care. Refer to LIC 421IM***

The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the serious bodily injury was due to neglect.

Exit interview conducted and a copy of this report, LIC9099D, and appeal rights were provided.

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20250915150444

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GRANT SERENITY HOMES OF BURBANK, INC	FACILITY NUMBER: 198603412
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/12/2026 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 (a)(2) - Personal Rights of Residents in All Facilities - (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodation ... This requiement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator has laid off the staffing registry caregiver. Administrator has retrained all staff members in regards to personal rights. POC cleared during today's visit.
	8 9 10 11 12 13 14	Based on interview, and record review, staff failed to provide adequate supervion, resulting in Resident 1 to go AWOL and to get injured and hospitaled, which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Mary G Flores
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

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