197609022-12-8-2021-28-AS-FFIS-CFVURE-20220630154835

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609022
Report Date: 12/08/2021
Date Signed: 12/08/2021 04:51:14 PM

Unsubstantiated

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
12/03/2021 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211203130302

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: 56	DATE:	12/08/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator Rosie Julinek		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff are not meeting the needs of the residents.
Food service inadequate.
There are no activities provided.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted an initial 10 day complaint investigation for the allegations listed above. LPA met with Administrator Rosie Julinek and discussed the purpose for todays visit.

The investigation consisted of the following: LPA interviewed staff #1-#5 (S1-S5) between 11:30am-12:30pm, Toured the physical plant from 12:30-1pm , Interviewed Resident #1-#6 (R1-R6) from 1-2:30pm. LPA also reviewed the following documents from 2:30pm-3:30pm: staff roster, resident roster, R1's file, Dietitian Notes, Food Menu, and Monthly Activities menu. Resident #7 (R7) was not available to interview. The Investigation revealed the following:

In regards to the allegation, "Staff are not meeting the needs of the residents", it is alleged that the facility is short staffed and unable to provide residents with proper care and supervision.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

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-20211203130302

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: 12/08/2021

NARRATIVE

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It was alleged that due to staff shortage R2 fell in their room and staff did not notice and that R7 has family arrive to the facility and do their laundry because there is not enough staff to do it. (5) of (5) staff interviewed denied the allegations. (6) of (6) residents could not corroborate the allegation. Interviews show that R2 fell in their room on 7/20/21. Resident notified staff through the phone and staff arrived to assist R2. Staff responded to residents call and R2 refused 911 service. Staff interviews also show that R7 has their family come to the facility and clean their room and do their laundry as a preference and not due to staff shortage. Staff provide weekly laundry services to all residents. Review of staff roster shows that facility keeps sufficient staff per shift. 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.

In regards to the allegation, "Food service inadequate." it was alleged that there was no knowledge of nutrition by cooking staff. (5) of (5) staff interviewed denied the allegations. (6) of (6) residents could not corroborate the allegation. Staff interviews conducted show that facility cook (S3) is knowledgeable of food nutrition and there is a list of residents with certain nutrition restrictions that must be followed. The staff are aware of this and design the menu accordingly as well as having a dietitian review and approve the food menu and food area monthly. LPA observed staff provided lunch to the residents as well as alternative meals to those who requested. 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.

In regards to the allegation, " There are no activities provided" it was alleged that there are announcements of activities and events, but they don’t happen. (5) of (5) staff interviewed denied the allegation. (6) of (6) residents interviewed could not corroborate the allegation. LPA was not provided with specific instances or examples. LPA reviewed the facility activities schedule for the month. The schedule states that activities for 12/8/21 are "10am Anne's Jewelry Boutique" , "12:45pm Bingo Tournament" and "2pm Memory Game". LPA observed the facility conducting these activities and observed residents participating during the visit. Interviews conducted also show that the facility provides multiple activities for residents to participate in daily. 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.

Exit Interview was conducted with Administrator Rosie and copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

LIC9099 (FAS) - (06/04)

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