197609022-3-1-2024-31-AS-NMAN-D55W3F-20240510165553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 03/01/2024
Date Signed: 03/01/2024 05:17:56 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
02/21/2024 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240221081352

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: 64	DATE:	03/01/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Amber Maczaczy, Executive Director		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Residents are not getting medications as prescribed
Untrained staff assisting with medication
Due to a lack of staff, residents are not assisted in timely manner
Staff smoking marijuana at the facility

INVESTIGATION FINDINGS:

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During investigation at 9:25a.m. LPA Alvizar- Ettima and Executive Director conducted a physical plant tour. LPA Alvizar-Ettima met with Executive Director, Amber Mzczaczy and explain the reason for the visit. Between 10:15a.m. – 3:15p.m. LPA conducted interviews with six (6) out of sixty-four (64) residents, Executive Director, Administrator, Wellness Coordinator and three (3) staff.

At 9:45a.m. LPA requested and reviewed medication administration documents.
1. Residents are not getting medications as prescribed
It was alleged that med techs leaving medications on night stands and tables not ensuring the residents take their medications.

During physical plant inspection, LPA did not notice any medications left in residents room.
Staff interviews reveal that residents are getting their mediation on time and as prescribed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

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-20240221081352

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 03/01/2024

NARRATIVE

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Interview with resident R#1 reveal that they received their medication as needed and med techs are making sure that they take the medication in their presence. Other residents interviewed did not express any concerns regarding their medication assistance.
A review of medication records did not reveal any discrepancies.

Based on observation, interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

2. Untrained staff assisting with medication

It was alleged that Med - Techs ask caregivers to assist the residents with medications without the proper training.

Staff interviews reveal that Med -Tech are not asking Caregiver to assist with medication. Staff indicated that some residents go to the Medication Room to receive their medication and they receive the pills from Med Techs only. Interview with resident R#1 reveal that they never received medication from a caregiver. Other residents also verified that medication was dispensed by the Med -Techs only.

Document review revealed that medication records are completed and signed by Med Techs only and all Med Techs received required medication training.

Based on observation, interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

3. Due to a lack of staff, residents are not assisted in timely manner

It was alleged that due to lack of staff, residents are not showered timely and are not changed timely. (R#1) not checked on during the night and was left soiled all night. (R#2) was found with no brief.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20240221081352

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 03/01/2024

NARRATIVE

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To investigate the allegation LPA Alvizar- Ettima interviewed staff and R#1 and R#2 residents. Resident R#1 reveal that they are very happy with staff help with incontinence care. Resident R#2 reveal that has never had an issue with incontinence care. Staff interviews reveal that staff assist in a timely manner and are fully staffed to assist residents with incontinence and showers. Staff interviews reveal that R#1 and R#2 are always assisted in a timely manner. Document review revealed that R#1 and R#2 do need incontinence assistance and received it as scheduled.

Based on observation, interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

4. Staff smoking marijuana at the facility

It was alleged that (S1) was smoking off a "weed pen".

To investigate the allegation LPA Alvizar- Ettima interviewed staff and residents. Staff interviews reveal that staff are not smoking marijuana in the facility. Staff interviews reveal that they have not witness any other staff smoking marijuana. Interview with residents reveal that have not seen staff smoking marijuana. During inspection, LPA did not smell any marijuana in common areas of the facility.

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

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

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