197607308-1-18-2022-29-AS-JAPL-CATVDT-20220119152117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607308
Report Date: 01/18/2022
Date Signed: 01/18/2022 12:07:01 PM

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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20200911093809

FACILITY NAME:	EVERGREEN CHATEAU		FACILITY NUMBER:	197607308
ADMINISTRATOR:	JOY MICHAYLUK		FACILITY TYPE:	740
ADDRESS:	13530 SHERMAN WAY		TELEPHONE:	(818) 902-9501
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	0	CENSUS: 0	DATE:	01/18/2022
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Joy Michayluk		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff are not meeting a resident’s needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to deliver the findings for the above allegations. The licensee for the above facility went through a change of ownership and this facility closed 02/01/2021. The LPAs met with the former licensee Joy Michayluk at the facility Ventura Villa Assisted Living (565850093) and explained the reason for the visit.

On 09/17/2020, LPA Aja Richardson conducted a virtual visit and interviewed three staff between 12:45 p.m. – 1:30 p.m., and conducted a virtual physical plant tour at 2:30 p.m. The LPA interviewed R1 on 9/15/2020 and reviewed pertinent documents.

CONT 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200911093809

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVERGREEN CHATEAU	FACILITY NUMBER: 197607308
	VISIT DATE: 01/18/2022

NARRATIVE

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Regarding the allegation, it was alleged that the facility failed to meet R1’s needs, as the facility allegedly cancelled R1’s doctor appointment. Interviews and records review revealed that R1’s health insurance changed, in which R1’s health care plan moved R1 from their current primary care physician to a different physician, whom had no knowledge of R1’s health care needs. R1 was made aware of this; thus, R1 attempted to make a doctor’s appointment with a new physician. However, a review of legal documents confirmed that R1 had a Power of Attorney whom oversaw R1’s health care needs. R1’s POA was aware of the change in physicians, and was working on ensuring that R1 remained with their current physician at the time the complaint was submitted. As such, R1’s POA authorized R1 to only see their current primary care physician, whom was still seeing R1 at that time, despite the changes in R1’s health care plan.

Documentation reiterated that R1’s POA did not want R1 to make any medical appointments and claimed that all medical needs had to be authorized through the POA. A review of R1’s physician report confirmed that it was completed by R1’s current physician, and it was also indicated that R1 was unable to leave the facility unassisted. R1’s POA reiterated that R1’s current primary care physician made visits to the facility to see R1, and that the POA was making arrangements to ensure that all of R1’s medical needs could be met by providers near the facility. The POA also explicitly stated that R1 could not leave unassisted as R1 was considered a flight risk. Whereas R1 may have been scheduling appointments on their own, they were not authorized by the POA.

Based on the information obtained, there is insufficient evidence to support the claim that staff failed to meet R1’s needs. It appeared that R1 was still able to have all medical needs met in a timely manner. Staff made sure to follow the directives of the POA, whom had control of R1’s health care needs. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

LIC9099 (FAS) - (06/04)

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