306003773-11-4-2021-22-AS-KLYN-C8FRPD-20211104131147

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003773
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:48:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	EVERGREEN CARE HOME		FACILITY NUMBER:	306003773
ADMINISTRATOR:	HAERYUN CHO		FACILITY TYPE:	740
ADDRESS:	4715 ST. ANDREWS AVENUE		TELEPHONE:	(562) 480-9453
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90621
CAPACITY:	6	CENSUS: 5	DATE:	11/04/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Haeryun Cho		TIME COMPLETED:	01:35 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) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Administrator Haeryun Cho and explained the reason for the visit. Administrator Haeryun Cho has an administrator certificate expiring on 06/14/2023. At 11:00 AM, LPA toured the facility with Administrator Cho. Facility is two stories with licensee living quarters on the second floor. Facility has five residents in care during today's visit, with one on hospice care. LPA observed residents relaxing in the facility. At 11:05 AM, LPA toured the unlocked garage and observed unsecured medications in the auxiliary refrigerator as well as unsecured cleaning supplies. Facility appears clean and sanitary. All resident's rooms had required elements as well as restrooms stocked with soap/ sanitizer. LPA observed three out of five residents are sleeping on mattresses on the floor without a bed frame. At 11:10 AM, LPA observed Resident 2 has full bed rails on the bed but no documentation of hospice care as well as unsecured cleaning items in the common restroom adjacent to resident's room. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident and staff temperatures daily but does not document. Facility has covid precaution postings as well as most required department postings. LPA toured the kitchen and observed ample food supply. At 11:20 AM, LPA observed two drawers and a cupboard contained unsecured medications and one cupboard contained unsecured vitamins and medications. There is a drawer with loose, unmarked medications. LPA observed unsecured cleaning supplies under the sink as well as in a hallway cupboard. Facility staff is using an "Aim and Flame" to start the burners on the cook top. Administrator states the cook top has been disabled from using the knobs to start the burners. Facility has completed the mitigation plan and plan has been approved. LPA observed emergency water as well as the first aid kit which contained all required items. LPA toured the outside grounds and observed the outside visitation area. Exit gate is unlocked and self latching. Residents participate in activities such as exercise and bible study. Facility has ample supply of PPE and cleaning supplies. All staff and residents are vaccinated for Covid-19. At 11:35 AM, LPA reviewed all resident files and CONTINUED ON LIC 809C DATED 11/04/2021

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EVERGREEN CARE HOME	FACILITY NUMBER: 306003773
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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. LPA observed unsecured medications in the unlocked garage refrigerator, and multiple cupboards and drawers in the kitchen. This poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/05/2021
	Plan of Correction
1 2 3 4	Licensee to secure all medications and forward proof to LPA by POC due date.

Type A

Section Cited

CCR

87705(f)(2)

The following shall be stored inacessible to residents with Dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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. LPA observed unsecured cleaning supplies in the unlocked garage, facility restroom, hall cupboard and under the sink. Additionally, LPA observed unsecured vitamins in an unlocked cabinet in the kitchen. This poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/05/2021
	Plan of Correction
1 2 3 4	Licensee to secure noted items and forward proof to LPA by POC due 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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EVERGREEN CARE HOME	FACILITY NUMBER: 306003773
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(B)

Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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. LPA observed Resident 2 has full bed rails and is not on hospice. This poses a potential health and safety risk to persons in care.
	POC Due Date: 11/11/2021
	Plan of Correction
1 2 3 4	Licensee to remove bed rails and forward proof to LPA by POC due date.

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EVERGREEN CARE HOME	FACILITY NUMBER: 306003773
	VISIT DATE: 11/04/2021

NARRATIVE

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three out of four residents with Dementia do not have an updated physician report.
Licensee has been requested to attend an in-office meeting at 770 the City Dr S Orange, Ca 92868 at 11:00 AM on Monday, November 8, 2021. Components of the visit as well as possible additional citations to be discussed at that time.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with Administrator Cho and a copy was provided as well as appeal rights.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC809 (FAS) - (06/04)

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