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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 09/24/2021
Date Signed: 09/24/2021 07:02:01 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2020 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200520093733
FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR:HEYMAN, AVIFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:99CENSUS: 55DATE:
09/24/2021
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Rosie Julinek TIME COMPLETED:
07:00 PM
ALLEGATION(S):
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9
Insufficient staffing
INVESTIGATION FINDINGS:
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13
An unannounced subsequent complaint visit was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan. Upon entering the facility LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. After the screening LPA met with administrator Rosie Julines and informed her the reason for this visit.

Regarding the allegation above: it was reported that the facility does not have sufficient staff. Staffing concerns were reported to the Department by the prior Administrator Jonathan Isaacs prior to the complaint submitted to the department.

The administrator at the time reported to the department that several staff resigned from their positions. Administrator was working dilligently to hire additional staff, by posting ads on various platsformes such as Indeed and Craigslist. When the staffng concerns began the administrator changed the staff scheules from 8 hour shifts to 12 hours and offered overtime to all staff.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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-20200520093733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
VISIT DATE: 09/24/2021
NARRATIVE
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During this visit at approximately 3:30 pm LPA conducted interview with the Wellness Director who confirmed that during the onset of the pandemic they has staff resigning constantly. The administrator was trying to hire staff but they were having a hard time because no one was applying.

From approximately 3:45 pm to 5:30 pm LPA conducted interviews with 6 residents. When interviewed residents confirmed that for "few months" the facility was having staffing issues because so many staff resigned because of the pandemic.

Based on the information reported to the department and interviews conducted during this visit the allegation is Substantiated, however due to the department being notified of the staffing issues prior to the reporting of the complaint which resulted from the pandemic and residents not reporting any care concerns a deficiency will not be issued.

Administrator Rosie Julinek was not able to stay at the facility and designated Med-Tech Abigail Leonin to sign for the report. Copy of this report and appeal rights was emailed to the administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2020 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200520093733

FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR:HEYMAN, AVIFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:99CENSUS: 55DATE:
09/24/2021
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Rosie Julinek TIME COMPLETED:
07:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to meet residents' needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
An unannounced subsequent complaint visit was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan. Upon entering the facility LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. After the screening LPA met with administrator Rosie Julines and informed her the reason for this visit.
Regarding the allegation above it was reported that due to lack of staffing residents needs were not met.
During this visit at approximately 3:30 pm LPA conducted interview with the Wellness Director who confirmed that during the onset of the pandemic they has staff resigning constantly, however the staff that were working were doing everything to make sure that the residents were taken care. From approximately 3:45 pm to 5:30 pm LPA conducted interviews with 2 of the 3 residents named in the compaint as well as 4 other resiednts who were living at the facility when the allegation was reported to the department. When interviewed 0 out of 6 residents complained about their needs not being met. Interviews revealed that at times it would take a little longer for assistance and some services such as showers were given at different times, however they continued to receive the care they needed therefore the allegation is Unsubstantiated.
Administrator Rosie Julinek was not able to stay at the facility and designated Med-Tech Abigail Leonin to sign for the report. Copy of the report was emailed to the administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3