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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 03/09/2024
Date Signed: 03/09/2024 04:32:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/04/2023 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 28-AS-20230104121616
FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR:ROSIO JULINEKFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:99CENSUS: 63DATE:
03/09/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Veronica CruzTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to close out the investigation regarding the above allegation. It was reported that in the morning of December 7, 2022, Resident 1 (R1) had a fall sustaining a head injury. First aid applied, but R1 was not taken to the hospital until later in the afternoon. The complaint was accepted by Investigations Branch (IB) Investigator Spindola on 01/05/23. The initial 10-day visit to this complaint was made by LPAs Cava and Gary Tan on 01/06/23. IB’s investigation consisted of interviews with the facility administrator, staff and residents. IB’s investigation also included review of R1’s medical records from the hospital and the skilled nursing facility (SNF) that R1 was discharged to. IB’s investigation revealed the following:
• 01/10/23: R1 and Resident 2 (R2) has lived at the facility for approximately four years.
• 01/24/23: Medical Records from the SNF revealed that R1 had a ground level fall
• 01/25/23: Medical Records from the hospital revealed that R1 was admitted to the hospital on 12/07/22 and discharged to the SNF on 12/14/22. R1 ambulates with a walker. R1 was found on the floor, in a pool
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
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 7
Control Number 28-AS-20230104121616
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
VISIT DATE: 03/09/2024
NARRATIVE
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of blood and bleeding from the head on 12/07/22 at the facility. It was unclear how long R1 was laying on the floor.

· 02/27/23: Interview with the facility administrator, Jonathan Perles confirmed R1’s admission in 2015, and acknowledges R1’s fall on 12/07/23. Interview with R2 confirms R1’s fall, but R2 could not recall much details of the incident. Interviews with Staff 1 (S1) and Staff 2 (S2) confirm R1s fall on 12/07/23, at approximately 3:00am, confirms the presence of blood to the forehead of R1, confirms cleansing and a band aid only applied, confirms that R1 was not sent to the hospital until 4:00pm on 12/07/23. Interviews with staff also confirmed that R1’s responsible person(s) was not notified of R1’s fall, but only of the hospitalization.

Although Staff was made aware of R1’s fall at approximately 3:00am in morning of 12/07/22, and only basic first aid was applied, staff did not seek the medical attention for R1 until 4:00pm that afternoon. Furthermore, a review of R1’s medical records indicate that since October 22, 2022, facility staff had knowledge of and acknowledged that R1’s cognitive and physical condition had progressed, continued to decline, and required assistance with hydration to prevent an infectious disease (sepsis), which caused R1’s brain to malfunction and experience a dysfunction that altered consciousness and behavior. Therefore, based on the information obtained, the allegation is Substantiated. Citation(s) issued on the 9099D.
Exit interview conducted. A copy of this report and appeal rights issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20230104121616
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2024
Section Cited
CCR
87465(g)
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Incidental and Medical Dental Care- The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis
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As POC, administrator will hold staff training to address this section of the regulations. As proof POC was completed, administrator will submit attendance log and training topic to the licensing agency by 03/18/24.
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This requirement was not met as evidenced by, R1 experienced a fall, suffered a head injury, and was found on a pool blood in the morning of 12/07/22. R1 was not sent to the hospital until the afternoon of that date. This poses an immediate health and safety risk to the resident in care.
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Type A
03/09/2024
Section Cited
CCR
87463(a)(3)
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Reappraisals- The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall
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Cont. continued to decline, and required assistance with hydration to prevent an infectious disease (sepsis), which caused R1’s brain to malfunction and experience a dysfunction that altered consciousness and behavior. This posed an immediate health and safety risk to the resident in care.
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include but not be limited to: Any illness, injury, trauma, or change in the health care needs of the resident. This requirement was not met as evidence by: a review of R1’s medical records indicate that since October 22, 2022, facility staff had knowledge of R1’s cognitive and physical condition progressing
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As POC, administrator will hold staff training to address this section of the regulations. As proof POC was completed, administrator will submit attendance log and training topic to the licensing agency by 03/18/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20230104121616
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2024
Section Cited
CCR
87455(c)(3)(B)
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Acceptance and Retention Limitations- No resident shall be accepted or retained if any of the following apply: Dementia, unless the requirements of Section 87705, Care of Persons with Dementia, are met.
This requirement was not met as evidenced by: a review of R1’s records indicate that
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As POC, administrator will hold staff training to address this section of the regulations. As proof POC was completed, administrator will submit attendance log and training topic to the licensing agency by 03/18/24.
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R1 began to express behaviors and symptoms of dementia. Staff was aware of this decline, but failed to accurately assess R1 in order to meet their needs. This posed an immediate health and safety risk to the resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/04/2023 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 28-AS-20230104121616

FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR:ROSIO JULINEKFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:99CENSUS: 63DATE:
03/09/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Veronica CruzTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff neglect led to severe dehydration of resident
Resident wandered away from facility due to lack of supervision
Staff did not notify responsible parties of a resident's unexplained absence from facility
Staff failed to administer residents medications as prescribed
Staff stole resident's belongings
Staff are not providing adequate food service to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to close out the investigation regarding the above allegations. Allegation #1: It was reported that Resident 1 (R1) was admitted to the hospital, on December 7, 2022 with severe dehydration. The complaint was accepted by Investigations Branch (IB) Investigator Spindola on 01/05/23. The initial 10-day visit to this complaint was made by LPAs Cava and Gary Tan on 01/06/23. IB’s investigation consisted of interviews with the facility administrator and staff. IB’s investigation also included review of R1’s medical records from the hospital and the skilled nursing facility (SNF) that R1 was discharged to. IB’s investigation revealed the following:

• R1 has lived at the facility since 2015 and was assessed to be an independent individual.
• R1 is able to eat and drink on their own.
• It could not be determined by facility staff, or if facility staff should have known that R1 was becoming dehydrated since R1 was deemed ambulatory and an independent individual at the time of IB’s investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20230104121616
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
VISIT DATE: 03/09/2024
NARRATIVE
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Based on the information obtained by IB, it could not be proven that staff’s neglect could have led to R1’s severe dehydration. Therefore, the allegation is deemed Unsubstantiated at this time.

The following allegations were investigated by LPA MIchael Cava on 03/09/24:

Resident wandered away from facility due to lack of supervision/Staff did not notify responsible parties of a resident's unexplained absence from facility:
In regards to the allegations, it was reported that R1 has been lost due to wandering multiple times for hours, but family was never notified by facility staff. There were no dates specified on when and how many times R1 has wandered away from the facility. Investigation to these allegations consisted of interviews with staff and record review. LPA was only able to identify one staff, Staff 1 (S1) who recalls when R1 resided at the facility. R1 moved out of the facility on or around June 2023. According to S1, R1 and their spouse Resident 2 (R2), never really left their room. Both residents had their meals delivered to their rooms. Both residents never participated in facility activities. Review of both R1 and R2's records reveal that both residents are ambulatory and able to leave the facility unassisted. Also review of facility incident reports for R1 and R2 show no record of either residents wandering away from the facility. Based on the information obtained, there wasn't enough evidence to prove R1 wandering away due to lack of supervision, nor staff not notifying R1's responsible person of the unexplained absences. Therefore, the allegations are deemed Unsubstantiated at this time.

Staff failed to administer residents medications as prescribed:
In regards to the allegation, it was reported that facility staff is supposed to check and assist R1 with medications as needed but failed to do so, for so long that it resulted in an infection. IB's investigation reveal that R1 is an independent individual. LPA's review of of R1's file reveal that R1 has the capacity for self care, which includes the ability to manage own medication, administer own prescription and PRN medication, and able to store own medications. Furthermore, there is signed documentation in R1's file, which indicates that R1 has read and understood their responsibility in keeping all medications stored in a lock box at all times, which would be the only way that R1 will be able to self medicate, control and maintain their medications. R1 was advised failure to do so will be in violation of Title 22 and Evergreens rules and regulations, subject to losing their right of self administering their medications. Signed and dated R1 on 06/14/18. A review of facility incident reports for R1 show no record for any medication error/management, which could have resulted in and infection and/or hospitalization, during their stay at the
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20230104121616
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
VISIT DATE: 03/09/2024
NARRATIVE
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facility. R1 moved out of the facility June 2023. Based on the information obtained, there was insufficient evidence to corroborate the allegation of Staff failing to administer R1's medications as prescribed. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff stole resident's belongings:
In regards to the allegation, it was reported that Resident 2's (R2) clothing was stolen by an employee but the bag of clothes were later returned. LPA conducted a review of facility incident reports for R2, but there is no record of R2's belongings reported being stolen during their stay at the facility. Furthermore, a review of resident file reveal that both R1 and R2 declined to fill out and complete the Client/Resident Personal and Valuables (LIC 621). R2 no longer resides at the facility. R2 moved out with R1 June 2023. Copy of their last service receipt notes that all their belongings were removed on 06/23/23. In addition, LPA conducted interviews with seven (7) of seven residents, who did not express any concerns of their belongings being lost or stolen. Note that the reporting party did indicate that the bag of clothes was later returned. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff stealing R2's belongings. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff are not providing adequate food service to residents:
In regards to the allegation, it was reported that food is inedible and low quality. R1 and R2 could not be interviewed regarding food service as moved out on 06/23/23. Interview with S1, who recalls when both R1 and R2 resided at the facility. According to S1, both residents had their meals delivered to their room. During their stay, both residents expressed no complaints or concerns regarding the food service. LPA conducted a physical plant inspection of the food service during meals, and did not observe food to be of low quality. Furthermore, interviews with seven (7) of seven residents expressed no complaints or concerns of the food service. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff not providing an adequate food service to residents. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7