197609022-10-12-2021-28-AS-FFIS-C89VBK-20211029161738

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 10/12/2021
Date Signed: 10/12/2021 03:06:12 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: 55	DATE:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Mele Tongamoa-Liu, Wellness Director		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility has insufficient staffing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an unannounced initial complaint visit on 12/20/2019 and unannounced subsequent visits on 09/14/2021 and 10/06/2021. The above allegation was from the original complaint; however, it was not addressed from the previous LIC 9099 reports. Therefore, on 10/12/21, LPA conducted a subsequent site visit, delivered finding and conducted an exit 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 and staff roster.

Allegation: Facility has insufficient staffing.

(-continued in LIC 9099C-)

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: 10/12/2021

NARRATIVE

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***This report serves as an amendment and supersedes the original complaint investigation report created on 10/12/2021. The finding remains Unsubstantiated. ***

The investigation revealed the following: During visit on 10/06/2021, the facility has fifty four (54) residents. Eleven (11) residents are dependence and need full care services. Forty-three (43) residents are independence. LPA Tao reviewed staff roster, it reported the facility has eight (8) caregivers and four (4) caregivers/Med Tech to provide cares to residents. A total of twelve (12) caregivers. Facility has one (1) Family specialist, one (1) Activity Director, one (1) Certified Dietitian, one (1) Head Chief, one (1) Wellness Director, one (1) Activity staff/ receptionist, one (1) Maintenance Director, three (3) kitchen staff, two (2) food servers, and two (2) housekeepers.

Per resident interviews, nine (9) out of thirteen (13) residents stated they received sufficient care from staff to take care of their daily needs. Three (3) out of thirteen (13) residents stated that at times, staff would take more than 10 minutes to assist residents who requested staff assistance; however, interviews with residents, indicated that staff were still able to meet the residents' care needs. One (1) out of thirteen (13) residents was unable to answer questions. Staff and Administrator interviews revealed residents' needs were met and staffing was sufficient. During the facility tour, LPA observed staff would respond to resident via intercom within a minute and would come to resident's room in about 10 minutes when they were called in the signal system.

Based upon observations, record reviews and interviews conducted, there is not a preponderance of evidence to prove the facility has insufficient staffing. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted and finding was discussed. 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: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC9099 (FAS) - (06/04)

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