197609022-10-12-2021-28-AS-FFIS-C89VBL-20211029161739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 10/06/2021
Date Signed: 10/12/2021 02:17:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/18/2019 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20191218104203

FACILITY NAME:	EVERGREEN RETIREMENT		FACILITY NUMBER:	197609022
ADMINISTRATOR:	HEYMAN, AVI		FACILITY TYPE:	740
ADDRESS:	225 NORTH EVERGREEN STREET		TELEPHONE:	(818) 843-8268
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY:	99	CENSUS: 54	DATE:	10/06/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Rosio Julinek, Administrator Mele Tongamoa-Liu, Wellness Director		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff failed to provide adequate food service to residents.

INVESTIGATION FINDINGS:

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***This report serves as an amendment and supersedes the original complaint investigation report created on 10/06/2021. The finding remains as Unsubstantiated. ***

Licensing Program Analyst (LPA) Tao conducted an unannounced initial complaint visit on 12/20/2019 and unannounced subsequent visit on 09/14/2021. Today, 10/06/2021, LPA conducted a subsequent site visit regarding the allegation listed above. LPA met with facility administrator, Rosio Julinek, and the purpose of the visit was explained.

The investigation consisted of interviews with Administrator, seven (7) staff, certified dietician, and thirteen (13) residents. LPA's observation of physical plant during the 12/20/19, 09/14/2021 and 10/06/21 visits. LPA reviewed Residents records, dietician contract and food menu.

Allegation: Staff failed to provide adequate food service to residents. It was alleged food provided at the facility did not meet residents’ dietary needs. (-contined in LIC 812C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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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Control Number 28-AS-20191218104203

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN RETIREMENT	FACILITY NUMBER: 197609022
	VISIT DATE: 10/06/2021

NARRATIVE

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***This report serves as an amendment and supersedes the original complaint investigation report created on 10/06/2021. The finding remains as Unsubstantiated. ***

The investigation revealed the following: Administrator denied allegation and stated that facility follow physician order and Certified dietician food menu based on resident’s dietary needs. Based on staff interviews, seven (7) staff and Administrator stated facility provided adequate food services to residents. Facility provided meals per certified dietician suggestions and measured servings of food during all mealtimes. Kitchen staff stated if residents requested, residents would receive second servings and an alternative food menu was available as well. Kitchen staff also stated they followed Dietician’s and Head chief’s guidelines when preparing food for residents. Per resident interviews, eight (8) out of thirteen (13) residents stated the quantity of food served was sufficient, taste was okay and adequate food services were provided. Four (4) out of thirteen (13) residents stated the food taste was too salty and adequate food services were provided. One out of thirteen (13) was unable to answer questions. Residents stated they received extra food if they requested it.

LPA’s observations during breakfast and lunch on 09/14/21 and 10/6/21, Residents were served the items listed on the food menu. LPA reviewed food supplies and observed dry goods, pasta, grains, can vegetables, frozen meats, frozen vegetables, milk, eggs, and fruits in the refrigerator. LPA did not observe expired foods. LPA reviewed facility's menu for 2 weeks from 09/05/21 to 09/18/21 and a variety of food was observed. Facility Dietitian stated that Food Menu was reviewed and updated monthly per residents’ needs.

Based upon observations and interviews conducted the findings indicate that, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted and finding was discussed with Mele Tongamoa-Liu, Wellness Director. A copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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