197609022-3-6-2024-31-AS-NMAN-D4ZV94-20240506161343

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 03/06/2024
Date Signed: 03/06/2024 11:09:06 AM

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
04/25/2023 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230425154440

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: 63	DATE:	03/06/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Amber Maczaczy, Executive Director		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff did not dispense medication as prescribed

INVESTIGATION FINDINGS:

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At 9:45a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegation. At 9:55a.m LPA met with the Executive Director and explained the reason for the visit.

During initial visit on 04/28/23 at 12:20pm, LPA conducted a physical plant check, between 12:30 pm – 2:27 pm LPA conducted interviews with staff involved with dispensing medication to R1 and R2, and at 2:50pm collected facility records, included but not limited to R1and R2 Identification and Emergency Information, Physician’s Report, Resident Appraisal, and MARs

During Licensing Visit conducted on 03/01/2024 at 11:27a.m. LPA Alvizar-Ettima inspected Medication Room. Between 1:00p.m. -2:27p.m. LPA interviewed residents including R1.

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: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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-20230425154440

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: 03/06/2024

NARRATIVE

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Prior to this visit on 02/28/2024 LPA Antonia Alvizar-Ettima reviewed the information and the documents previously obtained.

1. Staff did not dispense medication as prescribed.

It was alleged that resident #1 (R1) had not received their medication for two days and resident #2 (R2) was not receiving their medications as per doctor’s order.

Staff interviews reveal R1 and R2 have never missed medication. Sometimes residents forget that they already have taken medication. Staff #4(S4) revealed that R1 and R2 are able to manage their own prescription medication. Interview with R1 reveal that they did not miss medication. Records confirmed R1 and R2 are able to manage their own prescription medication. During Medication Room inspection, with S4 assistance, LPA crossed checked random selection of residents' MARs with the medications they have stored in the medication room. LPA did not observe 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.

No health and safety hazard is noted during this visit.

Exit interview is conducted and copy of report was provided to Executive Director.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC9099 (FAS) - (06/04)

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