197609022-5-17-2024-31-AS-NMAN-D5GPFF-20240521111640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:14:23 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
07/27/2023 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230727091900

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:	12:39 PM
MET WITH:	Amber Maczaczy, Executive Director		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's personal items were not safeguarded

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 9:50a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegation. 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, Admission Agreement and Resident Personal Property and Valuables. Between 11:20a.m. – 12:30p.m. LPA conducted interviews with three (03) out of three (03) staff and 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 six (6) out of seventy (70) residents.

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)

Page: 1 of 2

Control Number 31-AS-20230727091900

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Prior to this visit on 05/16/2024 LPA Antonia Alvizar-Ettima reviewed the information and the documents previously obtained.

1. Resident's personal items were not safeguarded.

It is alleged that R1 jewelry box was previously “ransacked and picked at” and now gone.

Staff revealed that when a resident leaves to the hospital and don’t come back the facility staff locks the resident room. R1’s belongings were locked in their room until R1’s family hired movers to pick them up from the facility. Interviews with seven (07) out of seventy (70) residents confirmed the information that staff provided. Residents have no concerns regarding facility staff not safeguarding personal items. A review of facility Resident Personal Property and Valuables document indicate that R1 did not identify a jewelry box on the personal inventory record.

Based on interviews and documents review there is no pertinent 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: 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)

Page: 2 of 2