<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003773
Report Date: 11/08/2021
Date Signed: 11/08/2021 11:50:48 AM

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 HOMEFACILITY NUMBER:
306003773
ADMINISTRATOR:HAERYUN CHOFACILITY TYPE:
740
ADDRESS:4715 ST. ANDREWS AVENUETELEPHONE:
(562) 480-9453
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY:6CENSUS: DATE:
11/08/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Haeryun Cho and Bong ChoTIME COMPLETED:
12:00 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
At this informal office visit, present were Licensing Program Manager (LPM) Alisa Ortiz, Licensing Program Analysts(LPAs) Kimberly Lyman and Kevin Saborit-Guasch as well as Licensee/ Administrator Haeryun Cho.and Licensee husband Bong Cho.

The following items were discussed during the meeting:
  • Citations previously cited on 11/04/2021
  • Additional citations provided during today's visit.
  • Residents sleeping on mattresses in the facility.
  • Facility keeping the upstairs living quarters inaccessible to residents.


Licensee has agreed to address all issues discussed during today's visit. Licensee was offered the Technical Support Program and agreed to participate. LPA to request a referral to the program for Licensee.








Based on the observations made during annual visit on 11/04/2021, additional 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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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 2
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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2021
Section Cited

1
2
3
4
5
6
7
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 req is not being met as evidenced by:
8
9
10
11
12
13
14
Based on record review, Licensee failed to ensure residents with Dementia have updated physician reports. Three out of four residents with Dementia do not have an updated physician report. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
11/22/2021
Section Cited

1
2
3
4
5
6
7
Equipment and supplies necessary for personal care and maintenance..: bed for each resident,... Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. This req is not being met as evidenced by:
8
9
10
11
12
13
14
Based on observation, Licensee failed to ensure all residents have functional beds. Three out of five residents are sleeping on mattresses only. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2