197609022-11-6-2023-31-AS-NMAN-D5ATJB-20240515144604

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:54:10 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.ASC, 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
11/01/2023 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20231101102521

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:	11/06/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Amber Maczaczy, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are financially abusing resident in care
Staff do not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Antonia Alvizar made an unannounced complaint visit to this facility. LPA was greeted by the Administrator, Rosie Julinek then Executive Director (ED) then Amber Maczaczy joined. LPA explained the purpose of the visit to ED.

Staff are financially abusing residents in care. It is alleged that staff took resident debit card and made multiple unauthorized charges.
To investigate this allegation, at 10:15a.m. LPA requested facility resident and staff roster. Approximately 10:40a.m. LPA and ED conducted physical plant tour. Between 10:55 a.m. and 2:00 p.m. interviewed four (04) staff, six (06) out of sixty-three (63) residents including resident #1 (R1). In addition obtained copies of R1’s Physician Report, Appraisal, Needs & Services, Unusual Incident Report, Personal Property & Valuables, and other relevant documents to the investigation. Staff revealed that R1 never provided them with a debit card and had not asked them to make a store run. R1 indicated that there is a debit card fraud but the bank has frozen the account and don’t think staff had something to do with it.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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-20231101102521

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 11/06/2023

NARRATIVE

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Interview of residents confirmed the information received from the staff. In addition, a review of R1 facility records at approximately 2:00pm – 2:30pm verify the information discussed during interviews. Based on interviews and record review there is no pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Staff do not safeguard resident's personal belongings. It is alleged that new debit card had been stolen from facility.

To investigate this allegations at 10:15a.m. LPA requested facility resident and staff roster. Approximately 10:40a.m. LPA and ED conducted physical plant tour. Between 10:55 a.m. and 2:00 p.m. interviewed four (04) staff, six (06) out of sixty-three (63) residents including resident #1(R1). In addition obtained copies of R1’s Physician Report, Appraisal, Needs & Services, Unusual Incident Report, Personal Property & Valuables, and other relevant documents to the investigation. Staff revealed that R1 never provided reported a missing debit card to them. R1 indicated that staff have exceed them expectations at this facility. Interview of residents confirmed the information received from the staff. In addition a review of R1 facility records at approximately 2:00pm – 2:30pm verify the information discussed during interviews. Based on interviews and record review there is no pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No immediate Health and Safety hazard is noted during this visit.

Exit interview conducted and a copy of the report was provided to Amber Maczaczy.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

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