197609022-4-24-2023-28-AS-NMAN-CUXSW7-20230822141351

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 04/24/2023
Date Signed: 04/24/2023 03:50:34 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2023 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230407144610

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: 67	DATE:	04/24/2023
		UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Executive Director, Jonathan Perles		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff failed to meet resident's grooming needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Antonia Alvizar made an unannounced subsequent complaint visit to deliver finding for the above stated allegation. LPA met the Executive Director and explained the reason for the visit.

LPA conducted a physical plant walk through, at approximately 10:16 am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit.

It is alleged that resident #1 (R1)'s grooming needs were neglected. R#1 hair was braided and new growned of hair looked tangled.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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-20230407144610

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 04/24/2023

NARRATIVE

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To invesdtigate this allegation, during initial 10-day complaint visit conducted on 04/17/23. LPA Alvizar conducted a tour of the physical plan about 4:00pm and spoke with the Executive Director (ED) at 3:53pm. LPA also obtained copies of rosters for residents and staff at 4:15pm.

At the time of this visit, between 10:49AM - 12:30PM LPA conducted interviews with 4 out of 4 staff involved with R1 care. Staff interviews revealed R1 is independent and able to groom, bathe and dress self. In addition, facility provides beauty salon services every Sunday for residents in care and residents could visit the hair salon if needed. A review of R1 facility records at approximately 1:20 pm verify the information discussed during interviews. Based on 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: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

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