197609022-2-16-2023-28-AS-TAGD-CWZMRY-20231027095103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 02/16/2023
Date Signed: 02/16/2023 03:53:12 PM

Substantiated

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
02/13/2023 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230213105132

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: 59	DATE:	02/16/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Jonathan Perles		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Resident inhaled and ingested hazardous chemicals

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director Jonathan Perles to conduct a complaint investigation, who was informed the reason of the visit. The following was determined:

During today's visit, from 12pm to 330pm, LPA conducted a physical plant inspection, obtained resident records, and interviewed staff and residents. It was alleged that resident #1 (R1) inhaled and ingested hazardous chemicals. During the investigation, and information obtained, R1 fell at the facility, and the paramedics were contacted and assisted R1. R1 refused hospital services, in which R1 stayed at the facility, and was assisted by the paramedics to R1's wheelchair. R1 fell again, and allegedly observed to be under the influence of alcohol. R1 admitted to the paramedics and staff, that R1 inhaled Lysol. During interviews, it was confirmed to LPA, that R1 did ingest a hazardous chemical. This a health and safety risk to residents in care. Therefore, based on interviews, the allegation is Substantiated.

Exit interview, appeal righs, and copy of report provided to ED.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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-20230213105132

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 02/17/2023 Section Cited CCR 87309(a)	1 2 3 4 5 6 7	Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met	1 2 3 4 5 6 7	Executive Director (ED) has AGREED to in writing, via email, by the POC date to LPA, how the facility is going to ensure how they plan to keep chemicals secured for residents. ED may request for
	8 9 10 11 12 13 14	evidenced by, during today's visit, it was revealed that resident # 1(R1) inhaled Lysol. This is immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	more time to correct the POC, once LPA has received the plan in writing.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC9099 (FAS) - (06/04)

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