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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200459
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:11:24 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/30/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231030085212
FACILITY NAME:EVERGREEN RESIDENTIAL CAREFACILITY NUMBER:
019200459
ADMINISTRATOR:OSUKA, ADA P.FACILITY TYPE:
735
ADDRESS:2292 N. LIVERMORE AVENUETELEPHONE:
(925) 487-1551
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:5CENSUS: 3DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ada Osuka, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not treat residents with dignity and respect
Staff falsified documentation
Staff withheld residents’ money
Staff violated residents’ personal rights
Staff withheld food from residents
INVESTIGATION FINDINGS:
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On 11/19/2024 at 12:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegations above. LPA met with Administrator, Ada Osuka and explained the purpose of the visit.

During the course of investigation, LPA interviewed 4 clients, 3 staff, and complainant. LPA also reviewed and obtained documents including client roster, staff roster with contact information, staff schedule, emergency information, Individual Program Plan, P&I log, facility menu, and care notes,

Staff did not treat residents with dignity and respect
Interview with clients revealed that staff are nice to clients and treat clients with respect. Client stated that C1 have hit staff before, but staff would redirect C1. Interview with staff indicated that staff treat clients with dignity and respect. Staff have not witness a staff be rude or mistreat clients and stated that staff are trained to redirect clients when a behavior occurs. (Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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 2
Control Number 15-AS-20231030085212
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EVERGREEN RESIDENTIAL CARE
FACILITY NUMBER: 019200459
VISIT DATE: 11/19/2024
NARRATIVE
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Staff falsified documentation
Interview with staff indicated that daily notes are completed after each shift and staff have not falsified documents. LPA observed daily notes are completed and there was a lack of evidence that documents were falsified.

Staff withheld residents’ money
Interview with clients revealed that clients are able to get P&I money when they ask staff. Clients stated there was no issues obtaining P&I money. Interview with staff indicated that P&I money are provided to clients when they need it. LPA reviewed P&I money with log and observed that P&I money was available to clients.

Staff violated residents’ personal rights
Interview with clients and staff indicated that toilet paper and hygiene supplies are available for clients. When clients ask for these items, staff will provide the supplies to clients. LPA observed facility had paper supplies and hygiene supplies available for clients.

Staff withheld food from residents
Interview with clients and staff revealed that clients have access to the pantry and refrigerator to obtain food items when needed. Staff stated that meals are provided to clients including breakfast, lunch, and dinner. Staff prepare client's lunch to take to the day program. LPA observed facility had 2 days of perishable and 7 days of non-perishable food supplies available.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
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