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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202812
Report Date: 05/02/2024
Date Signed: 05/02/2024 04:47:32 PM

Document Has Been Signed on 05/02/2024 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EVERGREEN HOMEFACILITY NUMBER:
435202812
ADMINISTRATOR/
DIRECTOR:		TRAN, ANTHONYFACILITY TYPE:
735
ADDRESS:5991 SOUTH SURF CT.TELEPHONE:
(408) 677-4520
CITY:SAN JOSESTATE: CAZIP CODE:
95138
CAPACITY: 6CENSUS: 6DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Staff Brandon VuongTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with staff S1, Brandon Vuong. During the visit, LPA observed 3 residents and 3 staff.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 110 degrees F in both resident bathrooms.

Fire extinguisher was serviced in September 23, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on March 1, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident P&I records. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 1 resident. While reviewing resident R5's medications, LPA discovered discrepancy. R5's Medication #1 has a start date of February 15, 2024. R5's Centrally stored Medication Records states medication #1 has a pill count of 60. LPA requested facility staff to count the pills, which resulted in 232 pills. ADM stated she is unsure why the medication bottle has so many pills. ADM stated it when R5 stayed overnight last weekend, the family may have mixed the refills.
Deficiencies are being cited during today's visit, see LIC809-D. This report was reviewed with Administrator Tran and a copy of the signed report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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Document Has Been Signed on 05/02/2024 04:47 PM - It Cannot Be Edited


Created By: Manuel Monter On 05/02/2024 at 04:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EVERGREEN HOME
FACILITY NUMBER: 435202812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(6)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (6) No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, the licensee did not comply with the section cited above. R5's Medication #1 has a start date of February 15, 2024. R5's Centrally stored Medication Records states medication #1 has a pill count of 60. Staff counted medication #1's pills, which resulted in 232 pills. ADM stated she is unsure why the medication bottle has so many pills, but stated the family may have mixed the refills. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2024
Plan of Correction
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ADM stated she send LPA plan of action on how she will ensure pills are not mixed and ensure the pill count for each medication matches the centrally stored medication log. ADM stated she will send the plan of action by POC date, May 9, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
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