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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200712
Report Date: 06/13/2024
Date Signed: 06/13/2024 05:10:43 PM


Document Has Been Signed on 06/13/2024 05:10 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 LIVINGFACILITY NUMBER:
019200712
ADMINISTRATOR:GARCIA, EMILYFACILITY TYPE:
740
ADDRESS:1710 MT DIABLO WAYTELEPHONE:
(925) 989-3345
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:6CENSUS: 6DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Remedios Manalang, CaregiverTIME COMPLETED:
05:30 PM
NARRATIVE
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On 6/13/2024 at 2:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Remedios Manalang and explained the purpose of the visit. The facility’s fire clearance was approved for 6 bedridden residents, of which 4 residents may be under hospice care.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, and outdoor area. Smoke and carbon monoxide detectors were observed. Sprinkler system observed. Fire extinguisher was observed to be full and last serviced on 6/5/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 105 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mats in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete.

LPA reviewed 6 residents and 4 staff files starting at 3:15PM. LPA interviewed 2 residents and 2 staff starting at around 4:00PM. LPA reviewed a sample of resident's medications during inspection.

At 3:45PM, LPA observed R1 does not have TB test on file.

At 4:00PM, LPA observed facility did not complete the disaster drill every quarter (every 3 months). Last disaster drill was conducted on 2/1/2024.

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

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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 06/13/2024 05:10 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: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not have TB test for R1 which poses a potential health and safety risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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Facility has agreed to obtain TB test for R1 and submit a copy to CCLD by POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not conducting a disaster drill every quarter which poses a potential health and safety risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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Facility has agreed to conduct disaster drill and submit log 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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