197609022-2-1-2023-28-AS-MVAO-CR8S42-20230425133200

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 02/01/2023
Date Signed: 02/01/2023 02:40:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 28-AS-20230126114049

FACILITY NAME:	EVERGREEN RETIREMENT		FACILITY NUMBER:	197609022
ADMINISTRATOR:	ROSIO JULINEK		FACILITY TYPE:	740
ADDRESS:	225 NORTH EVERGREEN STREET		TELEPHONE:	(818) 843-8268
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY:	99	CENSUS: 58	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:	Jonathan Perles - Executive Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility not safeguarding resident's personal items

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Executive Director Jonathan Perles and explained the reason for the visit.

LPA conducted physical plant tour at 10:00 AM, requested copies of facility documents relevant to the investigation at 10:20 AM and interviewed staff and resident between 10:30 AM to 1:00 PM. It was alleged that Resident #1 (R1)'s money was stolen sometime in December of 2022. LPA's interview today with R1 at 11:34 AM revealed that R1 could not recall the exact date and time the money was missing and unable to recall if R1 reported the incident to any staff. LPA's interview with the Executive Director at 11:15 AM also revealed that he did not receive any report of any missing money from any resident for the entire month of December 2022 and January 2023 and would have investigated it if it was reported to him. LPA's interview with the Wellness Director at 11:22 AM confirmed that there was no report of missing money of any resident for the past two (2) months. (Continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4364
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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-20230126114049

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 02/01/2023

NARRATIVE

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(continued from LIC 9099)

LPA record review at 12:15 PM revealed that per the facility's theft and loss policy, the facility is obligated to report to the local law enforcement if the resident's missing item is above $100, since R1 did not report to the facility the missing money however, there was no report nor any internal investigation was initiated by the facility. Further review also revealed that R1 did not declare any valuable on own personal and property and valuables form.

Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4364
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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