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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202663
Report Date: 11/22/2021
Date Signed: 11/22/2021 06:23:16 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2021 and conducted by Evaluator Steve Nguyen
COMPLAINT CONTROL NUMBER: 26-AS-20210913143102
FACILITY NAME:EVERGREEN HOME LIVINGFACILITY NUMBER:
435202663
ADMINISTRATOR:KUMAR, SASHIFACILITY TYPE:
740
ADDRESS:3291 SYLVAN DRTELEPHONE:
(408) 459-7888
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 3DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Thu NguyenTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff not providing adequate service to resident.
Staff failed to treat resident with dignity and respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Nguyen conducted an unannounced visit to deliver the complaint investigation finding. LPA met with Licensee Thu Nguyen.

On 9/15/2021, Licensing Program Analyst (LPA) Steve Nguyen interviewed reporting party (RP). RP stated that RP does not have any firsthand knowledge of allegations and does not have anything further to add.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20210913143102
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: EVERGREEN HOME LIVING
FACILITY NUMBER: 435202663
VISIT DATE: 11/22/2021
NARRATIVE
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On 9/15/2021, LPA conducted an inspection of facility with AD: Observed medication was locked, cleaning supplies locked, sharps are locked, all residents in common areas were well kept, all staff wearing masks and the practice of social distancing in effect. LPA requested the following documents but not limited to: resident and staff rosters, physician’s orders, progress notes, admission agreement, services and needs, and or available IPP, and LIC 634 Incident Reports for the year 2021.

From 9/15/2021 through 9/16/2021, LPA interviewed 5 Staff. 5 out of 5 staff denied any issues of neglect, and/or inadequate service pertaining to the Activities of Daily Living for residents. 4 out of 5 staff denied any incident concerning lack of respect for the residents from staff. 5 out of 5 staff stated that community outings do occur at facility.

On 9/15/2021, LPA attempted to interviewed 3 residents. 2 residents were non-verbal and/ or unwilling to be interviewed. 1 resident denied both allegations.

LPA reviewed the following but not limited to documents: resident and staff rosters, physician’s orders, progress notes, admission agreement, services and needs, and or available IPP, and LIC 634 Incident Reports for the year 2021. No instances of inadequate service or lack of respect for residents were found.

The Department has investigated the above allegations. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22

Exit interview conducted with Licensee Thu Nguyen and a copy of this report provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2