197609022-12-6-2024-31-AS-NMAN-DBWPW5-20241213104011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 12/06/2024
Date Signed: 12/06/2024 11:50:31 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.ASC, 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
08/30/2024 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20240830120239

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: 71	DATE:	12/06/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Amber Maczaczyj		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff are not adequately trained to meet resident needs
Staff do not assist resident's in a timely manner
Staff does not ensure that the facility is secure
Staff does not ensure residents are provided adequate food service

INVESTIGATION FINDINGS:

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At 10:30 a.m. on 12/06/24, Licensing Program Analysts (LPAs) Nicholas Reed and Nadia Shahbazian conducted an unannounced subsequent complaint visit. LPAs met with the administrator and disclosed the reason for the visit.

To investigate the above allegations, LPA Reed conducted an initial visit on 09/04/24 and toured the facility at 10:45 a.m., interviewed the administrator, staff, and a resident between 11:00 a.m. and 12:00 p.m., and obtained pertinent records at 12:00 p.m. On 09/11/24, LPA toured the facility at 10:40 a.m., reviewed pertinent records at 10:50 a.m. including but not limited to staff and resident lists, service plans, staff training records, and a physician’s report, and interviewed three (03) staff and four (04) residents between 11:00 a.m. and 2:30 p.m.

Regarding the allegation “Staff are not adequately trained to meet resident needs” it was alleged Staff #1 (S1) is not trained properly to transfer Resident #1 (R1).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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 3

Control Number 31-AS-20240830120239

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 12/06/2024

NARRATIVE

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Upon review of the staff list at 12:00 p.m. on 09/04/24, it was revealed that S1 was never employed at the facility. R1 did not wish to be interviewed for the investigation. LPA and the administrator reviewed training records which revealed all staff were sufficiently trained in transferring care and up to date on all trainings. Interviews with the administrator at 11:20 a.m. on 09/04/24, the Wellness Director at 11:00 a.m. on 09/11/24, and with Staff #2 (S2) at 12:30 p.m. on 09/11/24 revealed staff are trained for and competent in transferring residents. Interviews with five (05) out of five (05) residents revealed they have had no issues with staff transferring them to and from beds and wheelchairs. Based on interviews and record review, all staff are adequately trained to transfer residents. Based on interviews and observations, staff ensure residents are provided adequate food service. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff do not assist residents in a timely manner” it was alleged residents wait up to an hour for incontinence care. Interviews with five (05) out of five (05) residents revealed they have their incontinent needs met in a timely manner. Interviews with the administrator and Wellness Director revealed that resident rooms have pull cords near the bed and emergency pull cords in the bathrooms. Bathrooms emergency pull cords are prioritized higher and staff always respond as soon “within a couple of minutes”. Staff respond to non-emergency pull cord requests based on availability and urgency. LPA tested the facility call system in resident rooms between 12:00 p.m. and 2:00 p.m. on 09/11/24. Four (04) out of four (04) pull cords tested were operable. Staff arrived within five (05) minutes of each request. Based on interviews and observations, staff assist residents in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff does not ensure that the facility is secure” it was alleged residents are not safe because doors are unlocked from the outside. During physical plant tours on 09/04/24 and 09/11/24, LPA observed four (04) out of four (04) exterior side doors to be locked form the outside. The main entrance was unlocked. Interviews with the administrator and Wellness Director revealed that all side doors are locked form the outside at all times and the main door is locked around 5:00 p.m. everyday until about 6:00 a.m. There have been no issues with security or safety. Five (05) out of five (05) residents interviewed confirmed they feel safe and secure in the facility. Based on interviews and observations, staff ensure the facility is secure. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240830120239

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 12/06/2024

NARRATIVE

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Regarding the allegation “Staff does not ensure residents are provided adequate food service” it was alleged the facility serves food which is not nutritious. LPA observed lunch service at 11:45 a.m. on 09/04/24 and at 12:15 p.m. on 09/11/24 and observed food to be well-prepared and of adequate nutrition. Meals contained vegetables, proteins, and grains. Daily menus were posted in the elevator and on dining room tables. Interview with the head chef at 11:45 a.m. on 09/04/24 revealed some residents prefer alternatives to the food served, so the facility offers an alternate menu. Five (05) out of five (05) residents interviewed revealed they enjoy the facility food form the main and alternate menus. Based on interviews and observations, staff ensure residents are provided adequate food service. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health and safety risks were observed.
Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

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