197609022-10-29-2020-28-AS-MVAO-BXMUWQ-20210126145706

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 07/09/2020
Date Signed: 10/29/2020 10:46:31 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2020 and conducted by Evaluator Shawna Day

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200630164128

FACILITY NAME:	EVERGREEN RETIREMENT		FACILITY NUMBER:	197609022
ADMINISTRATOR:	HEYMAN, AVI		FACILITY TYPE:	740
ADDRESS:	225 NORTH EVERGREEN STREET		TELEPHONE:	(818) 843-8268
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY:	99	CENSUS:	DATE:	07/09/2020
		UNANNOUNCED	TIME BEGAN:	01:24 PM
MET WITH:	Jonathan Isaacs		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Facility did not administer medications as prescribed resulting in hospitalization.

Facility does not serve food of the quality to meet the residents needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shawna Day conducted a subsequent investigation visit to ascertain information pertaining to the above-mentioned allegations and to establish the validity of the complaint.
Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically.

During this investigation LPA requested and reviewed medication logs and prescriptions for R#1 for the month of June and July of 2020. LPA reviewed and requested the facility menu of the last 2 months. LPA conducted interviews with the following : R#1 - R#7, Administrator, Med Tech , Market Pharmacy and reviewed hospital discharge sheets from 6/24/20 and 6/27/20.

FACILITY DID NOT ADMINISTER MEDICATIONS AS PRESCRIBED RESULTING IN HOSPITALIZATION
This investigation revealed the following:
Resident #1 (R#1) was admitted to Ronald Reagan Medical Center on 6/11/20 and discharged on 6/24/20 at approximately 3:00 pm . R#1 was taking medication, Vimpat 150mg twice a day (1pill) at 8am and (1pill)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Shawna Day	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2020

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 28-AS-20200630164128

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 07/09/2020

NARRATIVE

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5pm. R#1 returned to the facility on 6/24/20 at approximately 3:00pm. R#1 had taken Vimpat 8am dosage at hospital as far as the 5pm dosage of Vimpat the Facility Med Tech informed family member that the medication (Vimpat) was at the pharmacy awaiting approval of payment by the family and then the Pharmacy would bring the medication over before 5:00pm dosage due. Family authorized medication at 3:00pm however medication did not come. Pharmacist informed LPA due to authorization late in the day the order did not process until the following day which was 6/25/20. At this point R#1 did not receive the following dosages: 6/24/20 5pm , 6/25 8am and 6/25/5pm. Family arrived back to facility on 6/25/20 and took R#1 back to the hospital for evaluation because she missed her medications at 9pm. R#1 was then readmitted on 6/25/20 for evaluation and discharged 6/27/20. In the meantime medication of Vimpat was approved and delivered to the facility at 5:00pm on 6/25/20. R#1 arrived to the facility from hospital on 6/27/20 at approximately 8:00am. At this time R#1 was given her Vimpat 150 mg dosage at 8:00am and has continued to get All medications timely. LPA finds that R#1 Vimpat medication had to be re authorized prior to medication being ordered. The facility did not know when R#1 was to arrive from the hospital. Upon arrival Facility requested medication right away. However due to the time R#1 arrived the medication did not arrive until the following evening. This is a special medication that requires authorization from the family. was waiting on family payment and was delivered same day as R#1 went back to the hospital. Facility noted R#1 doctor was called. LPA finds that the facility acted accordingly to order medication.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

FACILITY DOES NOT SERVE FOOD OF THE QUALITY TO MEET THE RESIDENT'S NEEDS
The investigation revealed the following: LPA reviewed the food menu which provides a Three nutritious meals to residents daily . Residents revealed that the meals are filling and nutritious , food is fresh and never cold when residents receive it. Facility staff and residents insists if ever something is not of the residents liking it is known it can be returned , heated and/or replaced. LPA toured the kitchen and food there to be abundant amount of perishable and non perishable food supply.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Shawna Day	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020

LIC9099 (FAS) - (06/04)

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