<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 09/29/2022
Date Signed: 09/29/2022 11:09:53 AM

Unsubstantiated


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
12/15/2020 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201215105826
FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR:HEYMAN, AVIFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:99CENSUS: 55DATE:
09/29/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee/Administrator, Avi HeymanTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's dietary needs are not being met .

Resident's room is not at a comfortable temperature.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #2 (S2: Theresa Williams, Med Tech - A.M.). LPA/RA spoke to S2 prior to entering the facility to conduct a risk assessment. S2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose of today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day virtual visit was conducted by LPA Nicol Wesley on 12/24/20 (via telephone) with (former) Administrator (A1:Jonathon Isaacs).

LPA/RA Ceniceros and Staff #2 toured (between 8:00 a.m. - 8:30 a.m.), the main dining room during the residents' breakfast time. LPA/RA Ceniceros interviewed (between 9:00 a.m. - 10:00 a.m.) 4 staff members and 5 residents in care. LPA/RA Ceniceros reviewed (between 10:00 a.m. - 10:30 a.m.) the requested pertinent documents for Resident #1: Emergency I.D. & Information, Physician’s Report, Resident Appraisal; including Food & Dietary Menus and facility's Maintenace/Repair Log.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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-20201215105826
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: 09/29/2022
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
Regarding Allegation #1: this investigation revealed based on the majority of the residents interviewed corroborated that their dietary and/or diabetic needs are being met. Facility staff interviewed indicated that they have not received complaints from residents regarding their dietary and/or diabetic needs not being met. LPA/RA reviewed Resident #1's Physician's Report (dated 05/16/18) that documents under "Physical Health Status" that the resident is on a special diet; however, the Resident Appraisal (dated 05/18/18) documents under "Health" that the resident does not have dietary limitations. LPA/RA toured the facility's commercial-size kitchen (between 8:00 a.m. - 8:15 a.m.) and observed a selection of dietary, diabetic, and regular food items (photos).

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident's dietary needs are not being met is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on the majority of the residents interviewed corroborated that their room temperature is at a comfortable setting for them. Facility staff interviewed corroborated that each of the residents likes their room to be at a certain temperature and have not complained to facility staff that their room is at an uncomfortable setting. LPA/RA Ceniceros toured the residents bedrooms (between 10:00 a.m. - 10:30 a.m.) and observed the rooms to be at a comfortable temperature; and, the thermostats (located in the hallways of the 2nd & 3rd floors) to read between 71*F - 74*F degrees (photos). A review of the facility's maintenance log (between 08/04/20 to 12/17/20 did not document A/C system needing repairs.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PHYSICAL PLANT: Resident's room is not at a comfortable temperature is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Licensee/ Administrator (Avi , Executive Director (Leana Silva), and Sandra Albarron (Regional Director).

SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2