019200712-6-10-2022-15-AS-GLUK-CF9SQQ-20220610140507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200712
Report Date: 06/10/2022
Date Signed: 06/10/2022 02:05:29 PM

Document Has Been Signed on 06/10/2022 02:05 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 SENIOR ASSISTED LIVING		FACILITY NUMBER:	019200712
ADMINISTRATOR:	GARCIA, EMILY		FACILITY TYPE:	740
ADDRESS:	1710 MT DIABLO WAY		TELEPHONE:	(925) 989-3345
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94551
CAPACITY:	6	CENSUS: 6	DATE:	06/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Remedios Manalang, Caregiver		TIME COMPLETED:	02:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/10/2022 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Caregiver, Remedios Manalang. LPA spoke with Administrator, Emily Garcia over the phone and was informed Administrator is unable to be at facility. Administrator authorized Caregiver, Remedios Manalang to sign CCLD report. Upon entry, caregiver did not conduct COVID-19 screening for LPA. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPA observed cough etiquette, signs & symptoms, and physical distancing are posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms. During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food supplies, and paper supplies are sufficient. At 9:50AM, LPA observed unlocked laundry detergents in the linen closet. Caregiver locked up laundry detergents during inspection. At 9:55AM, LPA observed sliding glass door in the living rooms is broken and unable to be opened. LPA tried to open the sliding glass door and was not able to open it. (Continue on LIC809C...)

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

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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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 SENIOR ASSISTED LIVING	FACILITY NUMBER: 019200712
	VISIT DATE: 06/10/2022

NARRATIVE

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At 10:00AM, LPA was informed that staff are using R1's room as an exit to the backyard.

At 10:05AM, LPA observed R2's room has a locked storage cabinet for facility's PPEs. LPA was informed that the cabinet use to be in the living room, but was moved to R2's room recently.

At 10:10AM, LPA observed medication cart was unlocked and refrigerator has unlocked medications. Staff locked medication cart and put medication in a lockbox in the refrigerator during inspection.

At 10:30AM, LPA observed side yard where exit gate is located has many items (wheelchairs, bed frame, suitcases, broken appliances) stored along the side yard.

At 11:00AM, LPA observed S1 does not have health screening during record review. LPA contacted licensee to obtain S1's health screening, but did not receive a copy prior to completing the inspection.

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

Exit interview conducted. A copy of this report and appeal rights was provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/10/2022 02:05 PM - It Cannot Be Edited

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 SENIOR ASSISTED LIVING	FACILITY NUMBER: 019200712
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having unlocked laundry detergents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/11/2022
	Plan of Correction
1 2 3 4	Caregiver locked up laundry detergents during inspection. Deficiency cleared.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having unlocked medication cart and unlocked medication in the refrigerator which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/11/2022
	Plan of Correction
1 2 3 4	Caregiver locked up medication cart during inspection. Caregiver found a lockbox to put the medication from the refrigerator and lock it during inspection. Deficiency cleared.

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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/10/2022 02:05 PM - It Cannot Be Edited

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 SENIOR ASSISTED LIVING	FACILITY NUMBER: 019200712
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having health screening for S1 which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/17/2022
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain S1's health screening and submit a copy 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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/10/2022 02:05 PM - It Cannot Be Edited

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 SENIOR ASSISTED LIVING	FACILITY NUMBER: 019200712
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having inoperable sliding glass door in the living room and items stored along the side yard near exit gate which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/27/2022
	Plan of Correction
1 2 3 4	Administrator has agreed to repair sliding glass door in the living room and remove items along the side yard by POC date. Administrator will submit picture/video proof that both sliding glass door is repaired and side yard is clear of storage items to CCLD by POC date.

Type B

Section Cited

CCR

87307(a)(2)(C)

Personal Accommodations and Services (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above by using R1's room as access to the backyard which poses a potential personal rights risk to persons in care.
	POC Due Date: 06/17/2022
	Plan of Correction
1 2 3 4	Administrator has agreed to conduct training to staff regarding resident's bedrooms shall not be used as a passageway. Administrator will submit training material and staff sign-in sheet 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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/10/2022 02:05 PM - It Cannot Be Edited

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 SENIOR ASSISTED LIVING	FACILITY NUMBER: 019200712
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468(a)

Personal Rights (a) Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in All Facilities, and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having PPE storage cabinet stored in R2's room which poses a potential personal rights risk to persons in care.
	POC Due Date: 06/17/2022
	Plan of Correction
1 2 3 4	Administrator has agreed to remove the PPE storage cabinet out of R2's room (room 5) and put it in a common area at the facility. Administrator will submit picture to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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