197609022-5-17-2024-31-AS-NMAN-D5HRCL-20240522125432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 05/17/2024
Date Signed: 05/17/2024 02:58:14 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
07/21/2023 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230721160221

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: 67	DATE:	05/17/2024
		UNANNOUNCED	TIME BEGAN:	10:56 AM
MET WITH:	Amber Maczaczy, Executive Director (ED)		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are not seeking appropriate medical services for residents
Staff force residents to accept emergency transport to the hospital

INVESTIGATION FINDINGS:

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At 9:50a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegations. LPA met with the ED and explained the reason for the visit.
During initial visit on 07/28/2023 at approximately 9:15a.m., LPA conducted a physical plan walk-through, at 9:40a.m. collected facility records, included but not limited to R1 ,Identification and Emergency Information, Physician’s Report, Resident Appraisal, MAR’s, Unusual Incident/Injury Reports, Progress Notes and Admission Agreement. Between 11:20a.m. – 12:30p.m. LPA conducted interviews with three (03) out of three (03) staff involved with R1 care. LPA also interview one (1) resident at the time of this visit.

During Licensing Visit conducted on 05/17/2024 at 10:10a.m. LPA Alvizar-Ettima and ED conducted a physical plan tour. Between (10:30a.m – 12:30am) LPA interviewed five (5) out of seventy (70) residents.
Prior to this visit on 05/16/2024 LPA reviewed the information and the documents previously obtained.

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: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

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-20230721160221

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: 05/17/2024

NARRATIVE

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1. Staff are not seeking appropriate medical services for residents.

It is alleged that facility are not helping residents to obtain appropriate medical care and will only call emergency services to transport patients to a local hospital, even for non-emergency

issues.

Staff interviews reveal that they always seek medical services for all residents as needed. They always communicate with the doctors and call paramedics per doctors request. Recently R1 was having nose bleeding on and off for about 2 weeks. R1’s primary physician was contacted and per doctor order R1 needed to go to the hospital. Staff contacted paramedics twice and R1 refused to go. R1 was not available to be interviewed. Interview with five (5) out of seventy (70) residents revealed that staff do seek appropriate medical services. Residents have no concerns regarding medical services provided by the facility staff. Information revealed from facility records supported the information provided by the staff.

2. Staff force residents to accept emergency transport to the hospital.

It is alleged that staff convince R1 to accept emergency transport to the hospital.

Staff interviews reveal that resident can not be forced to go to the hospital. Staff contacts emergency medical services based on the orders received from medical professionals. However, resident has a right to refuse to go to the hospital. Once staff calls 911 the decision is up to resident. All residents interviewed verified that staff never forced them to take emergency transportation to go to the hospital. R1 was not available to be interviewed. A review of facility internal incident log verified the information revealed from interviews.

Based on interviews and documents review there is an insufficient information to support the allegations. Therefore, the allegations are 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: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC9099 (FAS) - (06/04)

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