Inspection visit

Required - 2 YearDecember 14, 2018

BURBANK HILLS COMFORT LIVINGLicense 19760913512 citations on this visit

12 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Danyle Wolter arrived at the facility unannounced to conduct a Required 2 Year inspection. Upon LPAs arrival, S2 and S3 were present and contacted administrator, Narine Hannesyan (certificate # 6034425740 exp 3/31/19) , who arrived at 9:15am. Facility has a hospice waiver for three (3) and currently has one (1) resident on hospice. LPA conducted a file review at 9:20 am of two (2) staff records. S2 has criminal background clearance but is not associated to the facility, S3 has no criminal background clearance and is not associated to the facility. S1 and S2 do not have current First Aid training (exp 3/31/2017), staff has not completed twenty (20) hours of training in 2018. LPA reviewed five (5) residents files and found the files to be incomplete. R1 and R5 do not have physician reports, R1, R2, and R5 do not have Pre-Admission Appraisals, and R3 and R4 do not have reappraisals which have been completed in the last 12 months. LPA and administrator toured the facility together at 9:50am, including but not limited to: common living spaces, resident bedrooms; bathrooms, staff room/office, kitchen, and backyard. Facility has a garage in the backyard that was locked and administrator did not have a key to open it for inspection. Residents bedrooms and bathrooms were clean and in good repair, water temperature measured at 105.6 degrees F in resident bathroom. LPA observed adequate supply of extra towels and linens. Food supply for 2-day perishable and 7-day non-perishable was adequate. There is a pool in the backyard, pool is surrounded by a gate and is locked and inaccessible to residents. LPA observed fire extinguisher is fully charged and was purchased 10/28/18. LPA observed smoke detectors are present throughout the facility and are dual units with carbon monoxide detectors built in, they were tested and in working order. Report continued on LIC 809C LPA conducted a medication review at 10:15am and observed medications for R4 to be pre-poured for seven (7) days in a morning/afternoon/evening 7-day pill container. R4 also had multiple PRN medications and Vitamins which did not have physician orders, R4s 602 states they cannot determine their own needs for PRN medications. R4s prescription medications were unavailable as administrator stated they are stored in the locked garage. R3 had medications pre-poured in a 7-day pill container, R3 has physician orders but no medications were observed besides the medications which were prepoured and administrator told LPA that R3 takes no medications, administrator could not produce discontinue orders for medications. The following deficiencies were observed during today's inspection: S2 is working in the facility and is not associated. S3 was present in the in the facility and does not have criminal background clearance. S1 and S2 do not have current First Aid Training. Staff training has not been completed in 2018. Garage was locked and unavailable to be toured. R3 and R4 have medications pre-poured for 7 days. R3 has no discontinue order for medications with physician orders, medications were not observed on hand. Facility staff is not adequate in numbers R4 has PRN medications and Vitamins which do not have physician orders. R1 and R5 do not have physician reports in their files. R1, R2, and R5 do not have Pre-Admission Appraisals in their files. R3 and R4 have appraisals which have not been updated in the last 12 months. There were deficiencies found during today’s inspection. Deficiencies are cited from California Code of regulations, Title 22 and/or H&S Code 1569() and citations are listed on the attached LIC809D. If the deficiencies are not corrected by the noted due date, civil penalties may be assessed. Civil penalties were assessed during today's visit. S2 and S3 left facility during LPAs inspection, Administrator understands they are not to return until they have proper criminal background clearance and/or are associated to the facility. Exit interview conducted, appeal rights provided, and copy of report left at the facility.

Citations

12 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87355(e)(1)Type A
87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department orThis requirement is not met as evidenced by: when LPA arrived S3 was present at the facility and interacting with residents, S3 does not have criminal record clearance. Administrator told LPA that S3 has been volunteering in the facility for about a month and that she wanted to see how she did before she hired her. This poses an immediate health and safety risk to residents in care.
87355(e)(2)Type A
87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) orThis requirement is not met as evidenced by: upon LPAs arrival, LPA observed S2 to be present at the facility. LPA reviewed S2's file and did not observe a LIC 9182 for criminal record clearance transfer request to the facility. Administrator was unable to provide proof of transfer request. This poses an immediate health and safety risk to residents in care.
1569.625(b)(1)Type B
§1569.625 Staff training; legislative findings; contents (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision This requirement is not met as evidenced by: during LPAs file review LPA observed the only staff training completed in 2018 was dementia training, the other topics had not been covered. This poses a potential health and safety risk to residents in care.
87411(a)Type A
87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. [...] This requirement is not met as evidenced by: during LPAs inspection, LPA observed only administrator was able to assist all residents and prepare food for lunch. During file review, LPA observed the administrator is the only person associated to the facility and able to work. This poses an immediate health and safety risk to residents in care.
87411(c)(1)Type A
87411 Personnel Requirements - General(c) All RCFE staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by: during LPAs file review, LPA observed no staff to have current 1st Aid Training. This poses an immediate health and safety risk to residents in care
87457(c)Type B
87457 Pre-Admission Appraisal - General(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: during LPAs file review, LPA observed R1, R2, and R5 did not have Pre-Admission Appraisals completed before moving in. This poses a potential health and safety risk to residents in care.
87458(a)Type B
87458 Medical Assessment(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: during LPAs file review, LPA observed R1 and R5 do not have medical assessments in their files. This poses a potential health and safety risk to residents in care.
87463(c)Type B
87463 Reappraisals(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: during LPAs review of residents files, LPA observed R3 and R4 to have appraisals which have not been updated in the last 12 months as required. This poses a potential health and safety risk to residents in care.
87465(c)(2)Type A
87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: during LPAs medication review, LPA observed R3 to have medications prepoured in a 7-day pill container but no other medications on hand. Administrator told LPA that R3 does not take medications but could not provide discontinue orders for the prescribed medications on R3's LIC 602. R3's medications are not being given per physician orders. This poses an immediate health and safety risk to residents in care.
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87465(e)Type A
87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: during LPAs medication review, LPA observed R4 to have PRNs and Vitamins which did not have physician orders. LPA reviewed R4s 602 and R4 is unable to administer own PRN medications. This poses an immediate health and safety risk to residents in care.
87465(h)(5)Type A
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: during LPAs medication review, LPA observed R3 and R4 to have medications which were prepoured for 7 days in a morning/afternoon/evening in a 7-day pill container. Administrator was unable to show LPA original containers as they were stored in the garage and the garage was locked and unable to be accessed. This poses an immediate health and safety risk to residents in care.
87755(a)Type A
87755 Inspection Authority of the Licensing Agency (a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice.This requirement is not met as evidenced by: during LPAs tour of facility with administrator, LPA could not inspect garage outside because it was locked and administrator did not have a key. This poses an immediate health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the December 14, 2018 inspection of BURBANK HILLS COMFORT LIVING?

This was a inspection inspection of BURBANK HILLS COMFORT LIVING on December 14, 2018. 12 citations were issued: 8 Type A (serious) and 4 Type B.

Were any citations issued to BURBANK HILLS COMFORT LIVING on December 14, 2018?

Yes, 12 citations were issued (8 Type A, 4 Type B). The first citation was for: "87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Cod..."

What type of inspection was this?

This was a inspection inspection. inspection inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

Required - 2 Year·December 14, 2018