Community Care Licensing

Document Has Been Signed on 11/19/2024 04:49 PM - It Cannot Be Edited

Romeo Manzano TELEPHONE: (408) 277-1289 Chihhsien Chang TELEPHONE: (408) 904-9843 DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024

FACILITY NAME: EVCO CARE	FACILITY NUMBER: 435200918
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

Section Cited

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 in that resident room #1 and #4 were observed with little and waste scattered on the floor which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	Administrator stated to send a plan of correction by the POC due date to ensure the resident rooms without waste scattered on the floor.

Section Cited

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that staff S1 and S2 were observed without health screen form which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	Administrator stated to submit a plan of correction by the POC due date to ensure all staff have health screen forms prior to work for the facility.

Romeo Manzano TELEPHONE: (408) 277-1289 Chihhsien Chang TELEPHONE: (408) 904-9843 DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024

FACILITY NAME: EVCO CARE	FACILITY NUMBER: 435200918
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

Section Cited

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that the facility was unable to provide the document of staff training information which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	ADM stated to send a plan of correction by the POC due date to ensure the facility maintains the staff training documents.

Section Cited

(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and record review, the licensee did not comply with the section cited above in that the central stored medication forms of resident R1 and R2 were observed not updated and not matched with the residents' medications which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	ADM stated to send a plan of correction by the POC due date to ensure residents' central stored medication forms are maintained up to date.

Romeo Manzano TELEPHONE: (408) 277-1289 Chihhsien Chang TELEPHONE: (408) 904-9843 DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024

FACILITY NAME: EVCO CARE	FACILITY NUMBER: 435200918
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

Section Cited

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that resident R2's appraisal Needs and Service plan was conducted in year 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	ADM stated to send a plan of correction by the POC due date to ensure residents' appraisal needs and service plan are up to date.

Section Cited

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that no resident R1's admission agreement was maintained in the resident file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	ADM stated to send a plan of correction by the POC due date to ensure to maintain all the residents' admission agreement with signatures.

Romeo Manzano TELEPHONE: (408) 277-1289 Chihhsien Chang TELEPHONE: (408) 904-9843 DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024