019200712-6-20-2023-15-AS-GLUK-CSYUNY-20230620154444

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200712
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:44:54 PM

Document Has Been Signed on 06/20/2023 03:44 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: 5	DATE:	06/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Remedios Manalang, Caregiver		TIME COMPLETED:	04:00 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 6/20/2023 at 9:30AM, 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 7/5/2022. One week of nonperishable and 2-day of perishable food supplies were available. 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. The facility has a written emergency disaster plan. LPA reviewed 5 resident and 4 staff files starting at 11:00AM. LPA interviewed 2 residents and 2 staff starting at 1:30PM. At 10:15AM, LPA observed unlocked cleaning supplies in the laundry area. LPA also observed unlocked paints in the back yard. Staff locked up all the items during inspection. At 11:10AM, LPA observed R1 did not have a signed complete admission agreement on file. (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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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 06/20/2023 03:44 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: 06/20/2023

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 cleaning supplies in laundry area and paint in the backyard which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/21/2023
	Plan of Correction
1 2 3 4	Staff locked up the cleaning supplies and paint during inspection. Deficiency cleared.

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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/20/2023 03:44 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: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. 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 an administrator with current administrator certificate which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Facility has agreed to obtain current administrator certificate or documentation proof of active administrator certificate from ACP. Facility will submit current administrator certificate or documentation to CCLD by POC date.

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having complete medical assessment for R3 & R5 and no TB test results for R5 which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Facility has agreed to obtain complete medical assessment for R3 & R5 and TB test results for R5. Facility will submit medical assessments and TB test results 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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/20/2023 03:44 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: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: 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 current/complete reappraisal/needs and service plans for R2 and R5 which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Facility has agreed to obtain signed needs and service plans for R2 and R5. Facility will submit the signed needs and service plans to CCLD by POC date.

Type B

Section Cited

CCR

87507(d)

Admisson Agreements

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. 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 the complete admission agreement on file for R1 which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Facility has agreed to obtain R1's full admission agreement 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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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: 06/20/2023

NARRATIVE

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At 11:15AM, LPA observed R2's needs and service plan (ANS) is not signed and R5 does not have a reappraisal/needs and service plan.

At 11:20AM, LPA observed R3 and R5 has incomplete medical assessments on file. Also, R5 does not have TB test on file.

At 12:43PM, LPA checked Administrator Certification Program (ACP) website and observed Administrator does not have a current Administrator Certificate which expired on 7/31/22.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. 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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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