197609022-3-6-2024-31-AS-NMAN-D4ZV53-20240506160715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 03/06/2024
Date Signed: 03/06/2024 10:52:12 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
04/18/2023 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230418140931

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:	10:55 AM

ALLEGATION(S):

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Facility staff did not ensure that appropriate assistance was provided
Facility did not properly address bed bugs
Facility staff verbally harassed resident

INVESTIGATION FINDINGS:

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

During initial visit on 04/24/23 at 10:16am, LPA conducted a physical plant tour, between 10:49 am – 12:30 pm LPA conducted interviews with staff involved with R1 care, and at 11:30am collected facility records, included but not limited to Professional Pest Management Invoice, Resident #1 (R1’s) Identification and Emergency Information, Physician’s Report, Resident Appraisal, and Medication Administration Records.

On 02/27/2024 LPA Antonia Alvizar-Ettima reviewed the information and the documents previously obtained.

During Licensing visit conducted on 03/01/2024 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-20230418140931

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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1. Facility staff did not ensure that appropriate assistance was provided

It was alleged that the staff asked Resident #2 (R2) to move to resident #1 (R1’s) room to assist R1 due to changes in R1’s condition.

Staff interviews reveal that R2 was never asked to move in R1’s room to assist. Interview with R1 reveal that they do not want facility to move another resident in R1’s room. R2 verified that they were asked to move to R1’s room but was unable to explain why.

Document review revealed that R1 is ambulatory resident and able to transfer to and from bed and does not require assistance. During initial visit LPA Alvizar-Ettima observed R1 getting around the facility using a walker.

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. Facility did not properly address bed bugs.

It was reported that resident #3 (R3) had bed bug bites and told resident #2 (R2) that they got bed bugs because of R2.

Staff interviews revealed that facility did not have bed bugs. However, staff followed bed bug procedures just in case there were some bed bugs in R2 and R3 room. Staff asked R2 and R3 to temporarily move rooms for a deep cleaning. R3 moved with the assistance of a family member and R3’s room was deep cleaned, no bedbugs where found. R2 initially agreed to move to another room then refused therefore, R2’s room was not deep cleaned. R2 refused staff assistances in cleaning the room. Interviews with R2 and R3 revealed that they denied having bed bugs in their room. At the time of inspection, LPA did not observe bed bugs in R2 and R3 rooms. Document review from Professional Pest Management revealed that on 04/18/23, R2’s and R3’s rooms #209 and #210 were inspected and did not find any life bed bugs.

Based on observation, interviews and documents review 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: 03/06/2024

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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Control Number 31-AS-20230418140931

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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3. Facility staff verbally harassed resident.

It was alleged that the staff threatened resident #2 (R2) to throw them out the facility, due to R2 not allowing staff to treat the room for bed bugs.

Staff denied verbally harassing R2. Staff #1(S1) indicated that R2 agreed to move to another room temporary and then refused because they did not want to move personal belongings. Resident interviews revealed that they have not experienced or witnessed any staff to be verbally abusive. They indicated that they can always talk to staff without fear of retaliation. Staff are approachable, friendly, and nice. At the time of investigation, LPA did not observe any staff verbally harassing residents.

Based on observation and interviews 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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