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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 10/01/2021
Date Signed: 10/01/2021 05:48:39 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
03/05/2020 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200305085330
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:
10/01/2021
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Rosie JulinekTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not adequately staffed to meet the needs of residents
Residents are not being provided activities
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. LPA then met with Rosie Julinek Administrator.

On 3/13/2020 during the initial 10-day complaint visit LPA conducted interviews with staff working, obtained a current staff roster and activities calendar. On 9/24/2021 LPA conducted a subsequent complaint visit in regard to complaint control # 31-AS-20200520093733 at which time from approximately 3:45 pm to 5:30 pm LPA conducted interview with residents who were living at the facility early 2020. When interviewed residents did not believe the facility had insufficient staffing prior to the onset of the pandemic. Interviews were also conducted with members of the resident council who do not recall residents reporting staffing concerns in 2020 prior to the pandemic. All residents interviewed also confirmed that prior to the pandemic the facility always scheduled and provided various activities daily including on the weekends. Based on the information obtained from resident and staff interviews and documents obtained the allegations are Unsubstantiated. Exit interview conducted and copy of report emailed to the administrator Rosie Julinek.
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: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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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