197609022-6-12-2024-31-AS-AAEA-D66UVS-20240612155537

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609022
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:55:43 PM

Document Has Been Signed on 06/12/2024 03:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 69	DATE:	06/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Rocio Julinek		TIME COMPLETED:	04:00 PM

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

Licensing Program Analyst (LPAs) Antonia Alvizar-Ettima and Leizl De La Cerra conducted an unannounced Required One (1) year at this facility today. LPAs met with Administrator and explained the reason for the visit. Wellness coordinator, Jasmin Saldivar joined in the inspection. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools.

Resident age range 60 and over. 99 ambulatory, of which 50 may be non-ambulatory. A hospice waiver for 12 residents is in place. The facility does not have a Dementia waiver. Facility is a 3-story building consisting of 72 resident rooms, three (3) common areas, 1 living room/activity room, dining room, kitchen, beauty salon, 2 laundry rooms, underground garage and a courtyard patio areas. The facility maintains a comfortable temperature at 74°F. There are carbon monoxide detector installed in the facility. Fire extinguishers are located all throughout the facility and last inspected on 05/22/24. The facility is equipped with emergency pull alarm and sprinkler system.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located in the lobby. Sign in sheet, hand sanitizer, gloves and masks are available. Some staff were observed to be wearing mask during this visit. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility.

A tour of the physical plant was conducted at 10:30a.m. and the following was noted:
Kitchen: The kitchen appliances and fixtures were functional. Food Service area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food and properly stored. Knives and sharp objects were observed to be locked and inaccessible to residents. Walls, ceiling, and floor is in good repair, ample supply of dishes, cups, glasses and utensils for the current census.

Dining area: The dining area was observed to be neat, clean and in proper order. Walls, ceiling, tables, chairs and floor is in good repair.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/12/2024

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

Beauty Salon: The beauty salon was observed to be locked, clean and in proper order. It opens on Sundays only. Laundry rooms: Laundry rooms are located diagonally across from room numbers 208 and 308 on the second and third floor. All toxins such as laundry detergents, cleaning agents were observed to be locked inaccessible to the residents in laundry rooms.

Medication Room: Medications were kept in a locked medication carts in the medication room. The medications were observed to be locked and inaccessible to residents. There are multiple complete first aid kits located in the medication room. Medication and Medication Records were properly labeled and review for proper documentation.

Bedrooms: Six (6) randomly select rooms were adequately furnished with appropriate beddings and linens with sufficient lighting. Hygiene for residents was observed and hallways/passageways are lit. There were enough clean linen available in the closets.
Bathrooms: Six (6) randomly selected bathrooms were properly supplied, checked for cleanliness and had functional fixtures. LPA observed that there are appropriate grab bars in the showers and toilets. The hot water temperature measure range was between 111.2 – 114.3 degrees Fahrenheit.
Common Areas: These included the living room and dining area. All furnishings are in good repair, lighting is good, walls, ceiling and floors are also in good repair.

Surrounding Grounds: There is no body of water at the facility. Front yard and courtyard patio areas passageways were observed to be clear from obstruction. There are shaded area in the courtyard for residents.

Resident Files: LPAs conducted a file review of five (5) randomly selected resident records to ensure compliance of licensing forms. Residents’ files appear to be complete and updated.

Staff Files: LPAs also conducted a file review of six (6) randomly selected staff records to ensure forms and training are up to date and compliance with licensing forms. Staff files appear to be complete and updated.

Staff and Residents were also interviewed using the CARE Tools questionnaire. Facility emergency disaster plan was reviewed. Facility disaster drill was last conducted on 03/12/24. In addition to the physical plant inspection, residents and staff records were reviewed.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit

interview conducted. A copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2