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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 09/04/2024
Date Signed: 09/04/2024 10:46:43 AM

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: 71DATE:
09/04/2024
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Amber Leigh-Office ManagerTIME COMPLETED:
11:00 AM
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 visit to the facility to amend the 9099D page that was issued on 03/09/24. The above allegation was investigated by Investigations Branch (IB) Investigator Spindola. IB’s investigation consisted of interviews with the facility administrator, staff, and residents. IB’s investigation also included a review of R1’s medical records from the hospital and the skilled nursing facility (SNF) that R1 was discharged to. Based on the information that IB obtained, the allegation was Substantiated, which remains the same. The purpose of amending this report is to delete the continued citation, that was entered in the Plan of Correction (POC) box, and fit into the citations box. POC has since been corrected, therefore no further corrections will be needed. Office Manager advised and a copy of this report issued.
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: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
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 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: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2024
Section Cited
CCR
87463(a)(3)
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Reappraisals- In Part: (a) Pre-admission appraisal shall be updated as necessary…to note significant changes & keep appraisal accurate. Significant changes include: (3) Any illness or change in health care needs of the resident. This requirement was not met as evidenced by:
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The licensee has since submitted their POC, which was cleared on 03/18/24. No further corrections required.
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Based on LPA’s review of R1’s medical records which document since 10/22/22 staff had knowledge of R1’s cognitive/physical decline & increased needs for service. This deficiency 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: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
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