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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 04/23/2021
Date Signed: 04/23/2021 11:54:24 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/07/2020 and conducted by Evaluator LaJean Nicole Spencer
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200807130239
FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR:HEYMAN, AVIFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:99CENSUS: 65DATE:
04/23/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mele Tongamoa-LiuTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility did not safeguard resident's personal property.
INVESTIGATION FINDINGS:
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***This is an amended version of the report dated 9/14/20. The reason for the correction is to update the findings for the allegation.
Licensing Program Analyst (LPA) Spencer conduct a visit to deliver the findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Mele Tongamoa-Liu, medtech and Director of Wellness.
The investigation consisted of the following: On 8/14/20, LPA Spencer conducted telephone interviews with Marcia McKay, residents #1-3, and conducted a video call which consisted of a tour of the facility's medication room, the indoor and outdoor physical plant, and 2 resident rooms. The LPA received copies of the staff roster, staff contact information, resident roster, timecards for the last month, Admissions Agreement, Needs & Services plan for 5 specified residents, and driver log for August 3-5, proof of landline service bill, and screenshot of phone call on 7/29/20. During the course of the investigation, LPA also conducted interviews with residents #4-6, administrator Jonathan Isaacs and staff #1-2. **See LIC9099C for continuation of this narrative.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
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 3
Control Number 28-AS-20200807130239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
VISIT DATE: 04/23/2021
NARRATIVE
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***This is an amended version of the report dated 9/14/20. The reason for the correction is to update the findings for the allegation.

Facility did not safeguard resident's personal property.

It was alleged that the facility did not safeguard resident's personal property and a land line telephone and other valuables for R4 and R5 went missing at the facility. RP provided proof of the land line telephone through a copy of the land line service telephone bill. Based on interviews with the administrator, the facility does not have any safeguarded personal property however, some resident's have personal safes in their room. Administrator admitted that the facility does not keep a list of valuables for residents and if something is missing, the facility will do their best to find it, but the resident is responsible for replacing missing items. 6 residents were interviewed. 4 out of 6 residents said that they have never had personal property stolen or missing and 1 was unsure about missing property. 2 out of 2 staff stated that they are not aware of resident's missing property. Since the land line was purchased in 2018, no current staff were able to verify seeing the phone before it went missing. However, the administrator stated that he was made aware of the missing land line phone by R4 and R5's responsible party (RP) when he was first hired. He informed the RP that the facility was not responsible for replacing the missing land line phone. A review of the facility's admissions agreement reveals that their theft and loss policy is not in line with Title 22, stating that residents are solely responsible for lost or stolen property unless the missing property is shown to be caused by negligence of the staff. The administrator stated that they do not keep a list of valuables for residents and only follow the policy stated in their admissions agreement.

Based on interviews and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. CCR Title 22, Division 6, Chapter 8 is being cited on attached LIC9099D. An exit interview was conducted and copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200807130239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2021
Section Cited
CCR
87218(a)(3)
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87218(a)(3) Theft and Loss: The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. The facility contract of admission... shall not require or suggest a lesser standard of responsibility for the personal property of residents than the law requires. This requirement was not met as evidenced by...
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The licensee shall amend their Theft and Loss policy in the admissions agreement and provide copy to every resident or resident representative along with the LIC621 Client/Resident Personal Property and Valuables to complete. Licensee will verify and maintain an updated list in the residents file. Licensee will provide a copy of amended Theft and Loss policy to CCL and self certify that the LIC621 forms have been completed for each resident by 4/30/21.
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Based upon interviews and record review, the licensee did not ensure that the facility's Theft and Loss policy aligns with Title 22 requirements. This poses a potential risk for the personal rights of persons 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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3