197609022-3-15-2024-31-AS-NMAN-D55MR8-20240510094955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 03/15/2024
Date Signed: 03/15/2024 04:22:40 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
03/11/2024 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240311161636

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:	03/15/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Executive Director, Amber Mzczaczy & Adminstrator, Rosio Julinek		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not prevent a resident from stealing another resident's personal belongings

INVESTIGATION FINDINGS:

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At 12:00p.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced initial visit and was greeted by Executive Director (ED), Administrator and LPA explained the reason for the visit.

During investigation at 12:05p.m. LPA requested and received staff and resident roster. At 12:15p.m. LPA and ED conducted a physical plant tour. At approximately 12:35p.m. LPA requested R1’s Resident Personal Property & Valuables and Staff Notes. Between 12:40p.m. – 1:30p.m. LPA conducted interviews with ED, Wellness Coordinator (WC), three (3) out of sixty-three (63) residents and one (1) staff that provides care to resident #1 (R1). LPA was informed that resident #2 (R2) is no longer residing at the facility therefore unable to be interviewed.

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: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

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-20240311161636

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: 03/15/2024

NARRATIVE

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At approximately 1:30p.m. LPA received and reviewed R1’s Resident Personal Property & Valuables and a Staff Note. Between 1:35p.m. – 2:30p.m. LPA interviewed two (2) out of sixty-three (63) residents including R1 and one (1) staff via-phone that provides care to R1. LPA asked questions relevant to the investigation.

1) Staff did not prevent a resident from stealing another resident's personal belongings.

It was alleged that resident R#2 (R2) stole jewelry from resident R#1(R1).

Interview with resident R1 reveal that they stole a wedding ring but do not want to accuse another resident of taking it. Other residents interviewed did not express any concerns regarding residents stealing from them because every resident has a key to their room. Residents indicated that they are responsible of locking their room door at all times not facility staff. WC and staff interviews reveal that they do their best they can to prevent residents from stealing from other residents. Upon move in, staff provide every resident with their own key. A review of R1’s Resident Property and Valuables document dated 07/12/2023 indicates that R1 declined to record personal property and valuables.

Based on 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 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: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC9099 (FAS) - (06/04)

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