197608072-8-20-2024-28-AS-LHIS-D97MZZ-20240917100358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608072
Report Date: 08/20/2024
Date Signed: 08/20/2024 04:23:09 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/12/2024 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240812163333

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: 13	DATE:	08/20/2024
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Evangelina Reyes, Administrator		TIME COMPLETED:	04:24 PM

ALLEGATION(S):

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Staff did not ensure reporting requirements were followed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to facility to investigate the above allegation. LPA met with Administrator Evangelina Reyes and discussed the purpose of the visit.

The investigation consisted of Interviews with License (L) seven (7) staff (S#1-S#7) four (4) residents (R#1-R#4) and one (1) witness (W#1) reviewed of Admissions Agreement, and SIR dated 8/12/2024.

Allegation: Staff did not ensure reporting requirements were followed

The investigation revealed that R12 had an unwitness fall on 08/09/2024 at about 6:21PM and suffered a cut on her right hand. S3 contacted "administrator" Monica Kim to let her know. S3 tended to the wound. No other action was taken. The department received an Incident report on 08/12/2024 which described the incident and was signed by S1. S1 denied sending the report or authorizing anyone to use S1 name. The legal Licensee (L) denied sending the incident report and denied contacting the family about this incident.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240812163333

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/20/2024

NARRATIVE

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W#1 who is family member stated she still has not been contacted by facility to discuss resident's fall and injury. 6 (six) of 7 (seven) staff interviewed stated they did not notify family because they have been instructed by new Administrator S2 to report to her. S2 who reported to LPA that she is new Administrator has not submitted required paper work to department and is unable to act as administrator of facility. S2 who sent the incident report is not authorized to act on behalf of facility. S2 did not get permission to use S1 name on incident report and S1 did not know that S2 had use her name. As of the time of this report, the family and the department has not been officially notified by any authorized representative of facility of the incident that occurred on 08/09/2024 regarding C12 unwitness fall and injury.

Based on LPAs observations, interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.
Exit interview conducted, appeal rights given

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240812163333

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/23/2024 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211(a)(1). Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name,	1 2 3 4 5 6 7	Authorized personnel will contact family and submit incident report to department by POC date and write short explanation of how this would be avoided in the future.
	8 9 10 11 12 13 14	The authorized person acting on behalf of the facility did not submit an incident report for fall that R12 had on 08/09/2024. The incident report was submitted by unauthorized person by using current administrator name without consent. Family was never notified of incident by anyone to this date which poses/pose a health and safety hazard to persons in care,	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC9099 (FAS) - (06/04)

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