197608072-10-26-2021-28-AS-CDCN-C86QQ3-20211026122141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608072
Report Date: 10/26/2021
Date Signed: 10/26/2021 12:21:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	EVERGREEN SENIOR CARE		FACILITY NUMBER:	197608072
ADMINISTRATOR:	EVANGELINA REYES		FACILITY TYPE:	740
ADDRESS:	528 HOWARD STREET		TELEPHONE:	(626) 284-0503
CITY:	ALHAMBRA	STATE: CA	ZIP CODE:	91801
CAPACITY:	14	CENSUS: 12	DATE:	10/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Evangelina Reyes, Administrator		TIME COMPLETED:	12:25 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	Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator Evangelina Reyes and explained the reason for the visit. The facility is licensed for a capacity of 14 residents, of which 11 may be non-ambulatory and 3 bedridden. There is an approved hospice waiver for a maximum of 5 residents. During today's visit, LPA toured the physical plant, reviewed a sample of residents' file, and inspected the food supply. The following were observed: * Facility has one entry point and screened visitors upon entry. * There are 9 bedrooms and 7 bathrooms. Residents' rooms have the required furnishings for comfortable accommodations. The bathrooms have soap, paper towels, and signage for proper hand washing. * The facility has at least 30 days of PPE supplies available. * Disinfectants and knives are locked and inaccessible to residents. * The food supplies are adequate for the required 2 days perishable and a week of non-perishable. * Staff wore face coverings. * The 2 rooms in the garage were used as storage. The laundry area is also located in the garage. * The hot water temperature was measured at 115.3 degree F. * LPA reviewed 4 residents' file including their medication log and observed the following: Resident #1 did not have an updated medical assessment as required for individuals with dementia. Resident #1 ran out of medication Galantamine 4mg and had not obtained refill. Resident #3 did not have a physician's order for the Nature Bounty Vitamin B-12 that is being administered daily. Per California Code of Regulations, Title 22, the deficiencies observed during the visit are documented on the LIC809D. Exit interview held and a copy of the report, LIC809D, and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN SENIOR CARE	FACILITY NUMBER: 197608072
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. 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 which Resident #1's Physician's Report was dated 5/28/2020 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/09/2021
	Plan of Correction
1 2 3 4	The Administrator shall ensure that the Resident #1 receives an updated medical assessment by POC due date 11/9/21.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN SENIOR CARE	FACILITY NUMBER: 197608072
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

87465(c)(2) (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee ensure that Resident #2 medication Galantamine 4MG has been refilled timely to be administered as prescribed by the physician which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2021
	Plan of Correction
1 2 3 4	The Administrator shall ensure that Resident #2 Galantamine 4MG is refilled and submit a photo to LPA Chan by POC due date 10/27/21.

Type A

Section Cited

CCR

87465(a)(6)(A)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician. 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 for Resident #3 who was being given Vitamin B-12 without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2021
	Plan of Correction
1 2 3 4	The Administrator shall not administer Vitamin B-12 for Resident #3 until a physician's order is obtained. The Administrator shall self-certify that the medication has not been given and provide a statement that Regulation 87465 Incidental Medical and Dental Care has been reviewed by POC due date 10/27/21.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3