197609022-1-31-2024-31-AS-NMAN-D2EUUB-20240213145318

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 01/31/2024
Date Signed: 01/31/2024 06:34:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/25/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240125122220

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:	01/31/2024
		UNANNOUNCED	TIME BEGAN:	03:19 PM
MET WITH:	Rosio Julinek, Administrator		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Staff do not serve residents food of good quality

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with the administrator, Rosio Julinek, and explained the reason for the visit.

--- Staff do not serve residents food of good quality

It was alleged that the facility serves food that is always cold, overcooked or undercooked and that the facility does not offer a variety of foods. To investigate the allegation, on 01/31/2024, LPA conducted a physical plant tour at 3:30 PM, requested the facility menu at around 3:45 PM, interviewed three (03) staff from 4:00 PM – 5:30 PM and interviewed six (06) residents from around 5:30 PM – 6:30 PM. During the physical plant tour, LPA observed heating lamps to keep food warm and fresh foods being prepared. A review of the facility’s menu shows that residents are provided a variety of foods each day.
(CONT. on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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 31-AS-20240125122220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 01/31/2024

NARRATIVE

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During interviews with staff, all staff stated food is served hot, is not over or undercooked and that residents are served a variety of foods daily. During interviews with resident, R1 stated that food is not delivered immediately and cold when it arrives, that the food is either over or undercooked and that there are not being provided a variety of foods. All other residents stated that they are satisfied with the quality of the food, that the food is served fresh and hot, is neither over or undercooked and that they are pleased with the variety of food served.

Based on record review, observations and interviews there is enough not information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

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

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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