Inspection visit

Routine inspection (multi-day)March 17, 2022

BURBANK HILLS COMFORT LIVINGLicense 1976091359 citations on this visit

9 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing program analysts (LPAs) Jewel Baptiste and Noemi Galarza conducted an unannounced case management visit to reissue deficiencies and technical violations cited on 3/8/2022. LPAs was greeted by administer Narine Hannesyan and explain the reason for the visit. Upon arrival LPAs observed broken door bell. During todays visit LPAs toured the inside and outside of the facility.LPAs observed cleaning supplies unlocked and located in the hall closet. LPAs asked administrator about physicians orders for residents, to which she stated she is still working on it. LPAs also asked for in service training for staff, and administrator stated she trained staff but she did not keep record of the training. LPAs observed the garage is under construction and is being converted into Additional dwelling unit (ADU). Pool with required fencing was observed. The back yard is currently off limits to residents at this time. A change of operation and facility sketch will be submitted to Licensing with the updated information. During file review on 3/8/2022 LPA observed administrator certificate expired 3/31/2021, LPA checked CDSS online database and could not find the Administrator information (active/pending). On 3/11/22 LPA contacted admincertinfo@dss.ca.gov and they stated that they have not received anything from the administrator and the absence from the active/pending list is aligned with not having received a renewal application from the administrator for the 2021-2023 year. A technical violation was given on 3/8/22, LPAs will reissue citation with a type B violation. Report continued on 809c On 3/8/22 Staff#3 did not have criminal record clearance and was not associated to the facility. Per administrator Staff 3 has been living at the facility for three days. Staff left the facility during the visit. As of 3/17/22 S3 has been associated to the facility LPA issued type A violation and did not assess civil penalties at the time of the visit. LPA will reissue citation with civil penalties. During visit on 3/8/22 LPA Baptiste observed that all facility employee’s CPR card was expired. LPA issued a technical violation. LPA will reissue as a type B citation. On todays visit administrator showed proof of having CPR certification. During client file review on 3/8/22 LPA Baptiste observed Resident #1 file was missing pre-appraisal, needs and service and functionality capabilities form. Resident #2 physician report was blank, pre-appraisal, needs and service, and capability and functional form was missing. A technical violation was given on 3/8/22 and LPAs will reissue to type B citations. During medication review for residents#1 and #2 there was no physicians’ orders. LPA could not review medications. When LPA asked administrator how they administer medications to residents, she stated “we just read the bottle”. During today's visit, administrator has not obtained residents physicians orders. LPA will issue a type A citation. On 3/8/22, LPA Baptiste was informed by administrator Hannenesyan that the garage is being converted to a bedroom. LPA asked for a building permit and for Licensee to submit change of operation documents by 3/11/22. Administrator did not submit and or return phone calls. Due to technical problems on 3/8/22 LPA could not finish report to add information about garage. LPA was able to obtain a copy of the permit from city planning but has not received change of operation documents from Licensee. LPA will issue a type B citation. Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with administrator / Appeal Rights Discussed / A Copy of the Report Issued.

Citations

9 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.

87208(a)Type B
87208- Plan of Operation:Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met by evidence by: Administrator will ensure to submit a change of operation to CCLD and review regulation 87208(a) to ensure compliance in the future.
87355(e)(1)Type A
87355 Crimanal Record Clearance(e)All individuals subject to a criminal record review pursant 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 or This requirement is not met by evidence by: Based on record review on 3/8/2022, the licensee did not comply with the section cited above in 1 out of 1 Staff is not fingerprinted, associated or have background check clearance, which poses an immediate health, safety, or personal rights risk to persons in care.
87412(d)Type B
87412 Personnel Records: The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met by evidence by: Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff Administrator Certification expired 3/31/21.
87457(c)(1)(A)Type B
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. The appraisal shall include, at a minimum, an evaluation of the 87457 Pre admission Appraisal- General: prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors. The licensee shall be permitted to use the form LIC 603 (Rev. 6/87), Preplacement Appraisal Information, to document the appraisal. This requirement is not met by evidence by: Based on record review, the licensee did not comply with the section cited above in 3 out of 3 residents did not have preplacement appraisal and functional capacities in resident files, which poses an immediate health, safety or personal rights risk to persons in care.
Read full inspector narrative
87458(a)Type B
87458 Medical Assessment: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 by evidence by: Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents physicians report was blank and not update, which poses an immediate health, safety, or personal rights risk to persons in care.
87465(e)Type A
Incidential Medical & Dental Care: 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 the following information This requirement is not met by evidence of: Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents did not have physicians’ orders in resident files, which poses an immediate health, safety, or personal rights risk to persons in care.
87705Type A
The following shall be stored inaccessible to residents with dementia:Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met by evidence by: During LPAs tour facility staff had left cleaning supplies in hall closet.
87707(a)(2)(A)Type B
87707 Training Requirments: Direct care staff shall complete at least eight hours of in-service training about serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period. Direct care staff hired as of July 3, 2004 shall complete the eight hours of in-service training within 12 months of that date and in each succeeding 12-month period. A minimum of two of the following training topics shall be covered annually, and all topics shall be covered within a three-year period… This requirement is not met by evidence by: During record review on 3/8/22 and todays visit LPAs observe no staff training.
87412(a)Type B
87412 Personnel Records:The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: This requirement is not met by evidence by: Based- on record review, the licensee did not comply with the section cited above in 2 out of 2 Staff employee rights was not in their files, which poses an immediate health, safety, or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the March 17, 2022 inspection of BURBANK HILLS COMFORT LIVING?

This was a other inspection of BURBANK HILLS COMFORT LIVING on March 17, 2022. 9 citations were issued: 3 Type A (serious) and 6 Type B.

Were any citations issued to BURBANK HILLS COMFORT LIVING on March 17, 2022?

Yes, 9 citations were issued (3 Type A, 6 Type B). The first citation was for: "87208- Plan of Operation:Each facility shall have and maintain a current, written definitive plan of operation. The pla..."

What type of inspection was this?

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

SourceView on CCLD View original report

Next steps

If this is your facility,claim this pageand correct anything the record gets wrong. Free.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

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

Routine inspection (multi-day)·March 17, 2022