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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 10/04/2023
Date Signed: 10/04/2023 06:21:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
09/28/2023 and conducted by Evaluator Antonia Alvizar
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230928082746
FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR:ROSIO JULINEKFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:99CENSUS: 65DATE:
10/04/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff does not ensure facility is free of rodents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Antonia Alvizar arrived at 1:00PM to the facility to conduct an unannounced complaint visit for the allegations mentioned above. LPA met with the Executive Director Amber Maczaczyj, and explained the purpose to the visit.

During the course of the investigation, interviews and record review were made. At 1:05pm LPA requested copies of resident and staff roster. Approximately 1:13 pm – 3:00 pm LPA met with Culinary Director Luis Pacheco, Maintenance Arcadio Quijada, Executive Director Amber Maczaczyj, Administrator Rosie Julinek and conducted a physical plant tour. The facility Kitchen, lobby downstairs, dining room, reception desk, mailroom, activity room and three (3) randomly selected residents’ bedrooms also were inspected, and interviewed residents residing in those rooms. At 2:00pm Amber provided three (3) Service Inspection Report for Professional Pest Management to target ants, roaches and spiders.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 31-AS-20230928082746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
VISIT DATE: 10/04/2023
NARRATIVE
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Allegation: Staff does not ensure facility is free of rodents.
It is alleged that several mice are running around the lobby, dining room, reception desk, mail room, and activity room.
At the time of inspection, LPA observed glue traps in storage room/Culinary Director’s office, underneath kitchen sink and activity room. LPA observed rodent droppings in storage room/Culinary Director’s office metal shelf, plastic containers, cardboard boxes, behind shelves, food tin cans, food bags and underneath the reception desk and kitchen sink. Wall in kitchen underneath sink has holes that are covered with metal material.
Interviews with all staff members confirmed that the facility has rodents. The Service Inspection Report from Professional Pest Management indicated that they are not treating for rodents at this time. A review of facility records verified the information revealed from interviews.

Based on interviews, observation, and document review, there is a sufficient information to support the allegation. Therefore, this allegation is deemed Substantiated.

Deficiencies were issued and recorded on LIC9099D.

Executive Director, Amber Maczaczyj had to leave and designated Culinary Director, Luis Pacheco to sign the report.

No health and safety hazard were noted during this visit.
Exit interview conducted. Report signed and delivered. Appeal rights delivered.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20230928082746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2023
Section Cited
CCR
87303(a)
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87303(a) The facility shall be clean, safe, sanitary... at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met as evidenced by: Based on inspection, and observation
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The Administrator will take all measures to maintain the facility free from rodents. Administrator will submit updated documentation of Pest Control service agreement to LPA via fax by POC due date.
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the Licensee did not ensure that the facility is safe and sanitary for wellbeing of residents and others. LPA observed rodent droppings in food storage/office, kitchen and reception desk. This poses a potential health, safety risk and personal rights violation to residents in care.
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Type B
10/18/2023
Section Cited
CCR
80076(a)(17)
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80076(a)(17) Food Service. Kitchens, food preparation, and storage areas shall be kept clean... free of rodents, and other vermin. This requirement is not met as evidenced by: Based on inspection, and observation the Licensee did not ensure that the kitchen was free from rodents.
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The Administrator will instruct staff to cover holes on the wall to maintain the kitchen free from rodents. Staff will keep kichen clean at all times. Adminstrator will submit updated documentation of Pest Control service agreement to LPA via fax by POC due date.
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 LPA observed rodent droppings in storage room/office on metal shelf, containers, boxes, food tin cans, food bags and underneath kitchen sink. This poses a potential health, safety risk and personal rights violation to residents in care.
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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
09/28/2023 and conducted by Evaluator Antonia Alvizar
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230928082746

FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR:ROSIO JULINEKFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:99CENSUS: 65DATE:
10/04/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
06:30 PM
ALLEGATION(S):
1
2
3
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5
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7
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9
Staff does not ensure facility is free of pests.
INVESTIGATION FINDINGS:
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5
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7
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9
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13
Licensing Program Analyst (LPA) Antonia Alvizar arrived at 1:00PM to the facility to conduct an unannounced complaint visit for the allegations mentioned above. LPA met with the Executive Director Amber Maczaczyj, and explained the purpose to the visit.

During the course of the investigation, interviews and record review were made. At 1:05pm LPA requested copies of resident and staff roster. Approximately 1:13 pm – 3:00 pm LPA met with Culinary Director Luis Pacheco, Maintenance Arcadio Quijada, Executive Director Amber Maczaczyj, Administrator Rosie Julinek and physical plant tour. The facility Kitchen, lobby downstairs, dining room, reception desk, mailroom, and activity room and three (3) randomly selected residents’ bedrooms also were inspected, and LPA interviewed residents residing in those rooms. At 2:00pm Amber provided three (3) Service Inspection Report for Professional Pest Management to target ants, roaches and spiders.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20230928082746
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
VISIT DATE: 10/04/2023
NARRATIVE
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Allegation: Staff does not ensure facility is free of pests.
It was alleged that cockroaches have been seen multiple times in resident room.
Interview with resident #1 (R1) revealed that about two (2) months ago they had cockroaches in room but no cockroaches now. Interview with staff revealed that there are no cockroaches in the facility. The facility has hired pest control company, working on the pest situation at the facility. At the time of inspection, LPA did not observed any cockroaches in resident rooms. A review of facility records verified the information revealed from interviews. Professional Pest Management services the facility two (2) times a month for roaches.


Based on inspection, observation and interviews, there is an insufficient information to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Executive Director, Amber Maczaczyj had to leave and designated Culinary Director, Luis Pacheco to sign the report.

No immediate health and safety hazard is noted during this visit.
Exit interview conducted. Copy of report was provided.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5