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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200459
Report Date: 02/03/2021
Date Signed: 06/02/2021 01:38:33 PM

Document Has Been Signed on 06/02/2021 01:38 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: 4DATE:
02/03/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ada P. Osuka, Facility Administrator
Festus J. Osuka, Facility Administrator
Jake Reinhardt, Attorney		TIME COMPLETED:
02:00 PM
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On 02/03/2021, an audit solvency virtual visit was conducted with Delta Star Home Care, LLC and Paradise Residential Care, LLC. Attendees are as follows: Regional Manager Krystall Moore, LPM Czarrina Camilon-Lee, LPM Stephen Richardson, LPA Avelina Martinez, LPA Bruce Jacobs, Oakland Regional Office, LPM, Harpreet Humpal, LPA, Grace Luk, Jessica Chen Department Auditor, Facility Administrator, Ada P. Osuka, Facility Administrator, Festus J. Osuka, Attorney, Jake Reinhardt.

Throughout the course of the audit investigation, the Department conducted interviews and reviewed facility documents. Based on the audit investigation, the licensee shall meet the following financial requirements:

1. Develop and maintenance of a financial plan, which ensures resources necessary to meet operating cost for care and supervision of all clients.


2. Maintenance of financial records.
3. Submission of financial reports as required upon the written request of the Department or Licensing Agency.
4. Licensee shall provide monthly bills for 1 year-(utility, payroll, mortgage, credit card bills to the Department.)
5. Workers’ Compensation Coverage- (Provide the Department with Workers’ Compensation documents.)

Financial statements obtained throughout the audit investigation revealed, the licensee does not have a financial plan in place. Furthermore, the licensee does not have sufficient resources to meet the operating costs for all residents residing at Delta Star Home Care, LLC and Paradise Residential Care, LLC facilities: 1 thru 5. Bank statements indicate the licensee had a negative balance or low balance on four different bank accounts from 2019 through 2020. The reoccurring negative and low balance bank statements indicate, the licensee does not have the sufficient funds to maintain a cash reserve for emergencies. (Continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/03/2021
NARRATIVE
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Also, the income reported on the LIC 401, monthly operating statement form, was overstated. Supporting documents obtained during the audit, show less revenue coming in. It was learned that expenses were understated, and the net income was overreported.

Moreover, February 2020 credit card statements show partial or minimal payments being made. Consequently, the licensee incurred significant amount of interest charges, late fees, and unpaid ending balances. It was also learned some of the licensee’s facility mortgage payments were passed due, which resulted in late fees. Furthermore, on various occasions utility bills were not paid on time. As a result of unpaid bills, power and water were disconnected in November of 2019. In addition, water, sewer, and garbage were disconnected from the following billing periods: 12/9/2019-1/12/2020 and 1/13/2020-2/10/2020.

The licensee has also failed to provide requested documentation in a timely manner. The Department requested cable/ TV bills for Mercer Home Care and trash bills for Evergreen in February 2020. However, it took 10 months to receive the documents from the licensee. The licensee failed to provide workers’ compensation as of June 2018.

Based on audit documentation and information available, the following findings were determined:

1. The licensee does not have a financial plan that assures sufficient income to meet operating expense and is out of compliance of CCR 80062.

2. The licensee failed to provide documentation and information.

3. The licensee is not in a good financial position

4. Failed to follow administrator qualifications and duties

5. Failed to exercise general supervisor of the licensed facility operation.

As a result of this audit investigation, the licensee does not have sufficient resources to meet the operating costs for all residents residing at Delta Star Home Care, LLC and Paradise Residential Care, LLC facilities. The licensee has also failed to cooperate with the solvency audit and has failed to conform to the inspection authority regulation. Deficiencies are cited on the LIC 809-D, per Title 22 Regulations. The licensee’s attorney requested a plan of correction extension. The licensee’s attorney requested an extension to provide the plan of correction tomorrow, 02/04/2021.

An exit interview was conducted with Delta Star Home Care, LLC and Paradise Residential Care, LLC and a copy of this report was provided to Delta Star Home Care, LLC and Paradise Residential Care, LLC via email and an electronic email read receipt confirms receiving these documents. An appeals right document was also given to the licensee.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/02/2021 01:38 PM - It Cannot Be Edited


Created By: Grace Luk On 02/03/2021 at 01:12 PM
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: 02/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2021
Section Cited
CCR
80064(a)(3)(4)

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Administrator Certification and Qualifications. (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. (4) Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidenced by:
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1. Administrators shall make the facility expenses their priority and remit timely payments for all utilities, mortgages, and other operational expenses. Steps have already been taken to implement this plan by establishing automatic debit payments for many utilities and other charges, and Administrators will determine if additional automatic payments can be made on other accounts as well.
2. Going forward, the facilities will comply with CCLD's request for financial monitoring by providing an LIC401, utility bills, and mortgage statements to their respective LPAs on a monthly basis, with a copy sent to Audit
or Chen.
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Based on interviews and records review, the administrators did not ensure to maintain a financial plan and did not provide financial statements and other requested financial documents requested by the Department’s auditor, and have the documents readily available upon request from the Department. This posed a potential health and safety risk to residents in care.
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3. The facilities will maintain copies of utility bills, mortgage statements, and bank records so that documents can be made available to CCLD upon request going forward.
4. Licensees will secure workers' compensation insurance coverage.
5. Administrators will conduct a periodic review of bank statements and operating expenses and make adjustments as needed to ensure that the operation remains solvent.
Administrator will submit a self-certification to CCLD by POC date.
Type B
02/17/2021
Section Cited
CCR80062(a)(1)(2)(3)(A)

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80062(a)(1)(2)(3)(A)(B) Finances. (a) The licensee shall meet the following financial requirements: (1) Development and maintenance of a financial plan which ensures resources necessary meet operating costs for care and supervision of clients. (2) Maintenance of financial records. (3) Submission of financial reports as required upon the written request of the department or licensing agency. (A) Such request shall explain the necessity for disclosure. (B)The licensing agency shall have the authority to reject any financial report, and to request and examine additional information including interim financial statements. The reason(s) for rejection of the report shall be in writing. This requirement is not met as evidenced by:
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See Above.

Administrator will submit a self-certification to CCLD by POC date.
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Based on interviews and records review, the licensee did not ensure to maintain a financial plan and did not ensure to meet facilities’ operating costs. This posed a potential health and safety risk to residents in care.
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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: 02/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2021 01:38 PM - It Cannot Be Edited


Created By: Grace Luk On 02/03/2021 at 02:06 PM
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: 02/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2021
Section Cited
CCR
80044(a)(3)(4)

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Inspection Authority of the Licensing Agency. (a) The licensing agency shall have the inspection authority specified in Health and Safety Code Sections 1526.5, 1533, 1534, 1538, and 1538.7. (c)The licensing agency shall have the authority to inspect, audit, and copy client or facility records upon demand during normal business hours. Records may be removed if necessary, for copying. Removal of records shall be subject to the requirements specified in Sections 80066(c) and 80070(d). This requirement is not met as evidenced by:
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1. Administrators shall make the facility expenses their priority and remit timely payments for all utilities, mortgages, and other operational expenses. Steps have already been taken to implement this plan by establishing automatic debit payments for many utilities and other charges, and Administrators will determine if additional automatic payments can be made on other accounts as well.
2. Going forward, the facilities will comply with CCLD's request for financial monitoring by providing an LIC401, utility bills, and mortgage statements to their respective LPAs on a monthly basis, with a copy sent to Audit
or Chen.
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Based on interviews and records review, the licensee did not provide financial statements and other requested financial documents requested by the Department’s auditor and have the documents readily available upon request from the Department. This posed a potential health and safety risk to residents in care.
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3. The facilities will maintain copies of utility bills, mortgage statements, and bank records so that documents can be made available to CCLD upon request going forward.
4. Licensees will secure workers' compensation insurance coverage.
5. Administrators will conduct a periodic review of bank statements and operating expenses and make adjustments as needed to ensure that the operation remains solvent.
Administrator will submit a self-certification to CCLD by POC date.
Type B
02/17/2021
Section Cited
CCR80063(a)(1)

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Accountability. (a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation. (1) If the licensee is a corporation or an association, the governing body shall be active and functioning in order to ensure such accountability. This requirement is not met as evidenced by:
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See Above.

Administrator will submit a self-certification to CCLD by POC date.
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Based on interviews and records review, the licensee did not ensure to have sufficient funding resources to pay utility and other bills. This posed a potential health and safety risk to residents in care.
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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: 02/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2021


LIC809 (FAS) - (06/04)
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