197609022-5-17-2024-31-AS-NMAN-D5KSNT-20240524140203

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 05/17/2024
Date Signed: 05/17/2024 04:26:10 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.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
04/05/2024 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240405152252

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:	03:17 PM
MET WITH:	Executive Director (ED), Amber Mzczaczy		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff do not provide adequate food service to residents
Staff do not answer residents' call buttons in a timely manner
Staff stole residents' belongings

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 04/10/2024 at approximately 10:30a.m., LPA request and collected facility records, included but not limited to Alternative Menu, Alternative Menu Request form, and April 2024 Menu. LPA conducted a physical plan walk-through, at 10:45a.m. Between 11:00a.m. – 1:00p.m. LPA interviewed seven (07) out of sixty-six (66) residents including resident (R1). ED and other staff were interviewed at approximately 1:10p.m. LPA asked questions relevant to the nature of the complaint. The call button was tested from seven (07) randomly selected resident's rooms and interviewed.

During Licensing Visit conducted on 05/17/2024 at 10:10a.m. LPA Alvizar-Ettima and ED conducted a

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-20240405152252

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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physical plan tour. Between 1:00p.m -1:30p.m. LPA interview S1 and S2 was not available to be interviewed during this visit.

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

1. Staff do not provide adequate food service to residents.

It was alleged that facility food is low quality and not nutritious it is sometimes burnt, tough and the veggies and baked potatoes are served undercooked.

Staff interviews reveal that they have not received any complaints about inadequate food service. Facility provides an alternative menu if residents do not like what is being server for the day. ED indicated that cooks are always making sure the food menu is created with residents’ favorites and well prepared and they are open for residents suggestions. During interview R1 indicated that staff do not provide adequate food service. Interview with six (6) out of sixty-six (66) residents revealed that sometimes veggies are overcooked. Overall, the food is okay. When residents address their concerns about the food, the cooks resolve the issues. Residents interviews confirm that facility has an alternative menu which is available per residents’ request.

A review of facility main menu and alternate options supported the information provided by the staff.

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. Staff do not answer residents' call buttons in a timely manner

It was alleged that R1 pull they cord four (4) to five (5) times and staff do not answer because there are not enough staff in the facility.

During inspection LPA randomly selected seven (07) out of sixty-six (66) residents and the call buttons were tested in their rooms. All call buttons appeared to be functional, and LPA observed staff answering to call between three (3) to five (5) minutes.

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 3

Control Number 31-AS-20240405152252

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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Staff interviews reveal that they do answer residents’ call button in a timely manner. The medication room has a phone, and the med-techs walk around the facility with a cordless phone answering calls. The other departments have walkie talkies to communicated and respond to the call button calls. ED indicated that they manage calls to audit night shift to see if staff answer calls. Six (06) out of seven (07) residents confirm the information received from the staff. Only one resident (R1) addressed their concerns regarding call button. R1 was unable to provide specific details to clarify when the staff did not respond to the calls.

Based on observation and interviews there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

3. Staff stole residents' belongings

It was alleged that staff (S1 and S2) stole R1’s sweater and winter pants with Mickey Mouse on them.

Staff (S1) interview reveal that R1 has not reported missing a sweater and winter pants with Micky Mouse on them. S2 was not available to be interview at the time of this visit. ED indicated that if residents report missing belongings, first thing staff does is ask questions pertaining to the belongings. They then ask for permission to look through their stuff if not found. All staff members are informed about missing clothing. ED stated that no resident reported a missing sweater and winter pants with Mickey Mouse on them. Six (6) out of seven (07) residents interviewed during investigation had no concern about their personal belongings. R1 indicted that their belongings were missing, but they were unable to specify why it was not reported to the staff. The staff interviewed during investigation, denied stealing residents belongings. LPA reviewed R1’s Resident Personal Property and Valuables document and no personal items were recorded.

Based on interviews and record review, 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: 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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