197608072-6-20-2023-28-AS-CDCN-CSYVY2-20230620165026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608072
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:50:35 PM

Document Has Been Signed on 06/20/2023 04:50 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
GREATER LA AC/SC, 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:	06/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Evangelina Reyes, House Manager		TIME COMPLETED:	05:00 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	Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection. LPA arrived unannounced and met with Administrator, Evangelina Reyes. The purpose for the visit was explained. The facility is licensed to serve 14 residents, ages 60 and over. The fire clearance is approved for (11) non-ambulatory and (3) bedridden residents. There is a hospice waiver for 5 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff clean/disinfect twice a day. Facility has sufficient PPE supplies and has submitted an Infection Control Plan. Operational Requirements: The facility can accept or retain residents with dementia. They can also accept and retain up to 3 residents who are bedridden. There are currently 3 residents on hospice. Physical Plant & Environment Safety: The facility has 9 resident rooms, 7 bathrooms, living/dining room, kitchen, and a detached garage. There are no swimming pool or bodies of water on the premises. The hot water temperature was measured within the required range. There is an operable carbon monoxide detector in the hallway. Staffing: There is sufficient staffing at the facility. The administrator's (Evangelina Reyes) certificate expires on 7/8/23. Staff are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. The 3 Staff files reviewed have current CPR and first aid training and sufficient on-going training that meets the annual requirement. Resident Records-Incident Reports: LPA reviewed 3 Resident files and they have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights. Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical and mental capability.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN SENIOR CARE	FACILITY NUMBER: 197608072
	VISIT DATE: 06/20/2023

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Food Service: LPA observed sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator to avoid contamination. Incidental Medical & Dental: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. During the visit today, LPA reviewed 3 residents' medication and they are being administered as prescribed by the physician. Disaster Preparedness: The facility has the updated Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: The facility has residents on oxygen, receiving home health services, and/or hospice care.

No deficiencies were issued today. An exit interview was held and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
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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