197609022-3-28-2023-28-AS-NMAN-CSHPB6-20230605110950

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 03/28/2023
Date Signed: 03/28/2023 04:31:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2023 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230322105426

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: 65	DATE:	03/28/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director, Jonathan Perles		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Facility staff does not keep resident's room clean and free of trash
Facility staff are not meeting resident's care needd

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Antonia Alvizar made an unannounced complaint visit to this facility. LPA met the Executive Director, Jonathan Perles and explained that this visit was to conduct a complete investigation of the above noted allegations.
LPA conducted a physical plant tour at approximately at 10:30 am – 12:10 pm and inspected six (06) randomly selected residents bedrooms located on the 2nd and 3rd floors. During inspection, LPA Alvizar interviewed six (6) out of 65 residents including resident #1 (R1). In addition, LPA requested copies of pertinent documents relevant to the investigation at 1:30 pm.

It was alleged that facility staff does not keep resident’s room clean and free of trash.
Upon inspection, LPA observed the and residents’ rooms were clean and free of trash. All residents interviewed during this visit indicated that the rooms are being cleaned as required. R1 agree that housekeepers clean the room and remove trash as needed.
(Continue at 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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-20230322105426

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 03/28/2023

NARRATIVE

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(Continuation from 9099)

LPA conducted interviews with four (4) out of four (4) staff at approximately 12:30pm -1:30pm. Staff interviews revealed that all residents room are being cleaned per schedule and as needed.
Based on inspection, observation and interviews there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

It was alleged that facility staff are not meeting resident’s care needs.

To investigate this allegation, LPA conducted interviews with three (3) out of four (4) staff involving with the care of R1. Fourth staff was a housekeeper and was not involved in R1’s care. Staff interviews revealed that R1 is receiving required care and supervision as per their care plan. Medication assistance is provided as per doctor’s orders. In addition R1 is receiving hospice services and pain medication is managed by the hospice personnel. Interview of residents confirm the information received from the staff. In addition a review of R1 facility records at approximately 2:00pm – 2:30pm verify the information discussed during interviews. Based on observation, interviews and record review there is no pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC9099 (FAS) - (06/04)

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