197609022-11-21-2024-31-AS-NGID-DBUTHE-20241211134436

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 11/20/2024
Date Signed: 11/21/2024 10:25:29 AM

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
11/18/2024 and conducted by Evaluator Huma Rahimi

COMPLAINT CONTROL NUMBER: 31-AS-20241118112448

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: 72	DATE:	11/20/2024
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Amber Leigh, Administrator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff do not esnure residents are spoken to in an appropriate manner

INVESTIGATION FINDINGS:

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At 10:00 AM, Licensing Program Analysts (LPAs) Huma Rahimi, and Nadia Shahbazian, conducted an unannounced initial complaint visit. LPAs met with the Administrator and LPAs disclosed the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:55 AM, LPAs requested resident and staff roster. At 12:20 PM, LPAs requested copies of pertinent information which include, but not limited to Physician's Report, Appraisal Needs and Services Plan, Admission Agreement, and etc., relevant to the investigation. At approximately 12:25 PM, LPAs conducted a physical plant tour. Between 12:45 PM to 2:00 PM, LPAs conducted an interview with the Administrator, Wellness Director (WD), three (3) Staff, and seven (7) out of ten (10) residents.

Continue on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

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-20241118112448

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: 11/20/2024

NARRATIVE

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Staff do not ensure residents are spoken to in an appropriate manner:
Regarding the allegation Staff do not ensure residents are spoken to in an appropriate manner. It was alleged that the Wellness Director (WD) made upsetting comments about health treatments of R1. To investigate this allegation LPAs conducted interviews with the Administrator and (WD) and both parties denied the allegation. Interview with three (3) staff members revealed that they never witnessed nor heard that the (WD) spoke inappropriately or disrespectfully to anyone particularly to R1. Six (6) out of nine (9) residents interviewed expressed no concerns regarding this allegation. Lastly, interview with R1 confirmed that (WD) suggested R1 to go under physical therapy in order to use a walker. R1 also did not express any concerns regarding this all allegation.Based on the information gathered during the visit, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

LIC9099 (FAS) - (06/04)

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