306003773-12-8-2021-22-AS-KLYN-C9HRQC-20211208121318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003773
Report Date: 12/08/2021
Date Signed: 12/08/2021 12:13:27 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: 6	DATE:	12/08/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Haeryun Cho and Bong Cho		TIME COMPLETED:	12:25 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 made an unannounced plan of correction visit to follow up on citations issued on 11/04/2021 and 11/08/2021. LPA was greeted and granted entry into the facility by Administrator Haeryun Cho and explained the reason for the visit. Bong Cho was present as well. At 11:20 AM, LPA toured the facility and observed the following: Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Inaccessible Items has been cleared. All noted items have been secured. Licensee has complied with the terms of the POC. Deficiency cited under Title 22 Regulation 87608(a)(B) pertaining to Postural Supports has been cleared. Bed rails have been lowered below the bed ensuring rails are not being used. Licensee has complied with the terms of the POC. Deficiency cited under Title 22 Regulation 87705(c)(5) pertaining to Medical Assessments has been cleared. Facility obtained current physician reports for residents. Licensee has complied with the terms of the POC. Deficiency cited under Title 22 Regulation 87307(a)(3)(A) pertaining to Equipment and Supplies has NOT been cleared. Facility provided authorization from family for sleeping on the floor but no exception request to Licensing. Facility to submit exception request by 12/15/2021. CONTINUED ON LIC 809C DATED 12/08/2021

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

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
	VISIT DATE: 12/08/2021

NARRATIVE

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*Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Incidental Medical and Dental, Medications, has NOT been cleared. During tour of facility, LPA observed unsecured medications such as Aleve, Zenpep and acid controller. Licensee has NOT has complied with the terms of the POC. CIVIL PENALTY ISSUED.

Advisory note dated 11/04/2021 advised the following:

Facility does not have the "Let Us No" poster in the facility. Please post the poster in regulation size, 20" X 26." Poster is not posted in facility.
Facility does not have any covid signage at entrance of facility. Please post covid precautions/ visitor policy at entrance to facility. Facility has Covid signage at entrance.
Facility does not have hand washing signs in facility restrooms. Please post hand washing signs in restrooms. Facility has hand washing signs posted. Administrator advised to post instructional hand washing signs signs in restrooms
Facility does not have an ample supply of emergency food. Please obtain an emergency food supply. LPA observed ample emergency food during today's visit.

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 the facility representative 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: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

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: 12/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/09/2021 Section Cited	1 2 3 4 5 6 7	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 being met as evidenced by:
	8 9 10 11 12 13 14	Based on observation, LPA observed unsecured Aleve, acid controller, and Zenpep unsecured in a kitchen cabinet. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.	8 9 10 11 12 13 14
Type B 12/22/2021 Section Cited	1 2 3 4 5 6 7	Licensees shall prominently post personal rights.. complaint information in areas accessible to residents, representatives, and the public... complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows:Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility. This requirement is not being met as evidenced by:
	8 9 10 11 12 13 14	Based on observation, Licensee does not have the "Let Us No" poster posted in the facility. Licensee was advised on 11/04/2021 to post the poster. 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 Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

LIC809 (FAS) - (06/04)

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