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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200459
Report Date: 12/29/2022
Date Signed: 12/29/2022 12:16:53 PM

Document Has Been Signed on 12/29/2022 12:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ada Osuka, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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On 12/29/2022 at 9:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Ada Osuka and explained the purpose of the visit.

Upon entry, staff checked LPA's temperature prior to entry. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, living room, and outdoor areas. LPA observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks. Hot water was measured at 108.1 degrees F in the hallway bathroom sink.

During record review, LPA observed temperature logs for clients and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPEs, food, and paper supplies were sufficient.

At 9:55AM, LPA observed C1's exit side door has a key dead bolt from the inside and was locked. LPA was informed that the key dead bolt was put in when C1 moved in the facility.

At 9:59AM, LPA observed unlocked scissors in the kitchen drawer. Administrator locked up the scissors during inspection.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/29/2022 12:16 PM - It Cannot Be Edited


Created By: Grace Luk On 12/29/2022 at 11:41 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: EVERGREEN RESIDENTIAL CARE
FACILITY NUMBER: 019200459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked scissors in the kitchen drawer which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/30/2022
Plan of Correction
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Administrator locked up the scissors during inspection.

Deficiency cleared.
Type A
Section Cited
CCR
80072(a)(7)
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(7) Not to be locked in any room, building, or facility premises by day or night.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a dead bolt key lock on C1's exit side door which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/02/2023
Plan of Correction
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Administrator has agreed to relocate C1 to a different room by 12/30/2022 and remove/change key dead bolt on C1's exit side door by POC date. Administrator will send picture/video proof to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022


LIC809 (FAS) - (06/04)
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