197608072-9-17-2024-28-AS-LHIS-D9EL8B-20240924083138

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608072
Report Date: 09/17/2024
Date Signed: 09/17/2024 01:46:09 PM

Unsubstantiated

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
08/22/2024 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240822102637

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: 14	DATE:	09/17/2024
		UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Evangelina Reyes, Administrator		TIME COMPLETED:	01:59 PM

ALLEGATION(S):

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Due to lack of staff, residents are not being changed timely.
Due to lack of staff, residents are not being fed timely
Staff is not administering residents medications.
Facility does not have enough food for residents in care.

INVESTIGATION FINDINGS:

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

08/26/2024 - During today's visit, LPA Lopez obtained a copy of the resident/staff roster. LPA took tour of facility and checked food supplies. Facility had sufficient food for 2 day perishable and 7 day non-perishable.

The investigation consisted of LPA taking a tour of facility, checking food supplies, interviews with Seven (7) Staff and five (5) residents. LPA was not able to interview the other nine (9) residents due to communication barriers.
The investigation revealed:
Allegation: Due to lack of staff, residents are not being changed timely. It is alleged that there is not enough facility staff to meet the timely changing needs of residents. (Continued 9099C)

Unsubstantiated

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: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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-20240822102637

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: 09/17/2024

NARRATIVE

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LPA Lopez interviewed seven (7) staff and three (3) of seven (7) staff denied the allegation. LPA interviewed five (5) residents and three (3) of five (5) residents could not corroborate the allegation. LPA was not able to smell any odors and all residents stated they did not have any skin problems due to lack of changing. Some staff stated that they have been burdened with additional duties lately but somehow manage to provide care and supervision to residents. LPA observed staff feeding, cleaning and providing personal care to all the residents and no resident was neglected during the visits LPA made. There is not enough evidence to substantiate this allegation.

Allegation: Due to lack of staff, residents are not being fed timely. It is alleged that due to lack of staff, residents are not being fed timely.

LPA interviewed seven (7) staff and three (3) of seven (7) staff denied the allegation. LPA interviewed five (5) residents and three (3) of five (5) residents could not corroborate the allegation. LPA was present during two separate meal times and on both occasions, staff was able to feed all the residents in a reasonable amount of time. Some staff stated that their hours have been cut and that additional duties have been required of them which makes it more difficult to meet the resident's needs but that they manage. There is not enough evidence to substantiate this allegation.

Allegation: Staff is not administering residents medications. It is alleged that residents are not getting their medications.

LPA interviewed seven (7) staff and seven (7) of seven (7) staff denied the allegation. LPA interviewed five (5) residents and five (5) of five (5) residents could not corroborate the allegation. All staff and all residents interviewed stated they get their medication daily. There is not enough evidence to substantiate this allegation.

Allegation: Facility does not have enough food for residents in care. It is alleged that facility does not have enough food to feed the residents.

LPA inspected the food supplies on two (2) different visits and the facility had enough food for 2 days perishable and 7 days not perishable food at facility. (Continued)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240822102637

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: 09/17/2024

NARRATIVE

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LPA interviewed seven (7) staff and all seven (7) staff stated that the food supplies is not an issue at this time and that facility has enough food for all residents. LPA interviewed five (5) residents and five (5) of five (5) residents could not corroborate the allegation. All five (5) residents stated the get more than enough food. One resident stated that food is sometimes returned due to being too much for resident to eat. LPA observed meals provided to residents on two separate occasions and it was more than enough to feed all the residents. during those visit. There is not enough evidence to substantiate this allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held. A copy of the report and appeal rights was provided to Administrator Evangelina Reyes.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

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