197609022-7-31-2023-28-AS-RORN-CUHRMA-20230808130825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 07/31/2023
Date Signed: 07/31/2023 04:17:50 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
03/01/2022 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220301084219

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: 69	DATE:	07/31/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Rosie Julinek		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident's toileting needs are not being met.
Facility is not meeting resident's hair care needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Rosie Julinek and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Administrator Rosie Julinek, Staff 1-4 (S1-4) and Residents 1-6 (R1-6). LPA collected copies of Staff and Resident rosters. LPA reviewed R6's facility file and collected copies of documents relevant to the investigation.

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) -98-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: 323-981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

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-20220301084219

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: 07/31/2023

NARRATIVE

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Investigation revealed the following: Regarding allegations, Resident's toileting needs are not being met and Facility is not meeting resident's hair care needs, it is alleged that a facility resident was covered in their own urine and feces and their hair was so matted it will need to be cut. Interviews conducted with Administrator and S1-4 revealed that residents are assisted within 5-10 minutes of their requests, and residents who require toileting assistance are regularly checked on every 2 hours. Staff denied that any resident was covered in urine and feces and also denied that any resident had matted hair. Staff also stated that residents that need assistance with hair care needs are assisted on a daily basis or as needed and they are given a shower 2-3 times per week and as needed. Interviews conducted with 4 out of 6 residents revealed that they require assistance with toileting and hair care needs and are assisted timely and they do not have any concerns with staff not meeting their toileting and/ or hair care needs. They also stated the facility staff provide assistance with showers, and changing as needed, staff ensure that residents are clean. 2 residents stated that they are independent and do not require assistance with toileting or hair care needs and stated that they are satisfied with the services and do not have any concerns. 1 resident stated that they do not require assistance with hair care needs or toileting needs and denied that their hair has been so matted that it needed to be cut. They also denied ever being covered in urine and/ or feces. LPA review of documents reviewed revealed that R6 is able to bathe self, dress/ groom self and is able to care for their own toileting needs. During the visit, LPA observed that 6 out of 6 residents that were interviewed were clean, their hair appeared clean and not matted and LPA did not notice an incontinence odor. Based on statements gathered from interviews conducted with staff, residents, LPA review of documents and observations, there was not enough supportive evidence to concur with the reported allegations.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Administrator Rosie Julinek.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) -98-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: 323-981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC9099 (FAS) - (06/04)

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