197609022-4-23-2021-28-AS-MVAO-C2PQK4-20210504121342

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 09/14/2020
Date Signed: 04/23/2021 11:49:49 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
08/07/2020 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200807130239

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: 65	DATE:	09/14/2020
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Mele Tongamoa-Liu		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not maintain adequate staffing to meet resident's needs.
Facility did not answer communications to the authorized representative promptly or appropriately.
Facility did not provide authorized representative with proper notification of rate increases.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

***This is an amended version of the report dated 9/14/20. The reason for the correction is to add additional details.
Licensing Program Analyst (LPA) Spencer conducted a visit to deliver the findings for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Mele Tongamoa-Liu, medtech and Director of Wellness.
The investigation consisted of the following: On 8/14/20, LPA Spencer conducted telephone interviews with Marcia McKay, residents #1-3, and conducted a video call which consisted of a tour of the facility's medication room, the indoor and outdoor physical plant, and 2 resident rooms. The LPA received copies of the staff roster, staff contact information, resident roster, timecards for the last month, Admissions Agreement, Needs & Services plan for 5 specified residents, driver log for August 3-5, proof of landline service bill, and screenshot of phone call on 7/29/20. During the course of the investigation, LPA also conducted interviews with residents #4-6, administrator Jonathan Isaacs and staff #1-2. ***See continuation of report on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021

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 2

Control Number 28-AS-20200807130239

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: 09/14/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

***This is an amended version of the report dated 9/14/20. The reason for the correction is to add additional details.
Facility did not maintain adequate staffing to meet resident's needs.
Based on review of the timecards from July-August and LIC 500 Personnel Report, there are sufficient caregivers and Medtech staff to assist residents on any given shift. 3 staff were interviewed and 3 out of 3 staff indicated that there are 2 caregivers per shift plus a Med tech. The administrator stated that there are a total of 6 caregivers and 3 med-techs. 6 residents were interviewed and 4 out of 6 residents stated that there are enough staff to assist them if they need help. During the incident of resident #5 falls and injury on 7/7/20, the resident stated that she fainted in her room and someone called for help. The administrator stated that the resident was immediately helped by staff, administered first aid, and asked if she would like for them to call 911 but resident declined.
Facility did not answer communications to the authorized representative promptly or appropriately.
A total of 6 residents were interviewed. 5 out of 6 residents stated that the facility administrator communicates with their authorized representative promptly and appropriately, and issues are communicated to them in a timely manner. The administrator stated that when residents or family members call, he will call them back as soon as he receives the message. He stated that the facility uses a driver to transport residents to appointment twice a week and was unaware of resident not being picked up for an appointment. Upon review of the driver logs, it appears that resident #5 was not listed on 8/4/20. During the incident when police were called on 7/29/20, the administrator stated that he was not aware that the police were called until they arrived around 11:00 a.m. He stated that he informed the responsible party (RP) on the same day that the incident happened once he was made aware of the situation. A review of the call log provided by RP shows that the administrator called RP the same day to report the incident on 7/29/20 at 4:11 p.m.
Facility did not provide authorized representative with proper notification of rate increases.
Based upon review of the admissions agreement, it states that any rate increases will be communicated in writing 60 days in advance. Based on interviews with the administrator and RP, a rate increase notice was provided 60 days in advance.
Based upon physical plant observation, interviews conducted, and documents reviewed, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) areUnsubstantiated.
A telephonic exit interview was conducted with Mele Tongamoa-Liu. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2