486801323-8-11-2023-21-AS-ACAA-CUM7U6-20230811215749

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801323
Report Date: 08/11/2023
Date Signed: 08/11/2023 09:58:24 PM

Document Has Been Signed on 08/11/2023 09:58 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	JT EVERGREEN CARE HOME		FACILITY NUMBER:	486801323
ADMINISTRATOR:	COPERO, JOHNNY		FACILITY TYPE:	740
ADDRESS:	115 MICHAEL CRT.		TELEPHONE:	(707) 557-0180
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	08/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:48 AM
MET WITH:	Johnny Copero		TIME COMPLETED:	03:34 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) Araceli Canela arrived unannounced to conduct an Annual Required 1 Year inspection and met with care staff, Jason Orot and Alexander Olayvar. Administrator was called; was in an appointment and unable to come to the facility immediately and arrived a few hours later. During todays visit individual identified as new owner of the property, Claribelle Bailon, arrived and explained, an application will be submitted to Community Care Licensing for a change of ownership. Current licensee, Johnny Copero is the Administrator, running the facility and has control of this property located at 115 Michael crt. LPA requested facility to submit copy of Lease Agreement by 8/11/2023. LPA initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 106 degrees F which is within the required range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinet in garage containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility maintains emergency food and water supplies. Fire extinguishers were fully charged and last serviced February 9, 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent disaster drill was conducted 5/2023. Staff have required First Aid certificates that expire 2/2025 but no proof of CPR. Administrator Certificate for Administrator, Johnny "Juanito" Copero, 6017113740, expires on 6/11/2024. Training records were reviewed. Required postings were observed. Medication records were reviewed. Continued Report see LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: JT EVERGREEN CARE HOME	FACILITY NUMBER: 486801323
	VISIT DATE: 08/11/2023

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Two staff files and four resident files were reviewed. Staff S1 and S2 were found to have fingerprint clearance, but not associated to this facility as required. Administrator showed LPA Caregiver background check completed in which they noted both facility numbers for S1 and S2 to be associated. Administrator was advised to do separate forms and not combine 2 facility numbers when doing this process and the facilities responsibility to ensure all staff present have properly been associated prior to working. Administrator completed the required forms to associate the staff and faxed the documents to community care licensing during inspection. Administrator was advised, failure to ensure staff, have the proper fingerprint associations will result in civil penalties.

Licensee/Administrator to submit updates of the following documents by 9/10/2023:

LIC 500 Personnel Summary- received during visit
LIC308 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan (If changes) received during visit
Infection Control Plan (If changes)
Copy of Liability Insurance
Copy of Administrators Certificate

Copy of Lease Agreement for Control of the property due: August 12,
2023

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided by email.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/11/2023 09:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: JT EVERGREEN CARE HOME	FACILITY NUMBER: 486801323
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(4)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on todays visit and review of records with Administrator, staff S1 and S2 were fingerprint cleared and associated to their other facility and not to this facility as required. The licensee did not comply with the section cited above in 2 of 2 staff records reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2023
	Plan of Correction
1 2 3 4	Facility completed forms and sent to CCL, in addition Facility to send in written plan on how they will ensure they meet regulation to LPA A Canela by 8/15/2023.

Type B

Section Cited

CCR

87463(c)

Reappraisals

(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 todays record review with Administrator, the licensee did not comply with the section cited above in 2 of 5 records reviewed for resident R1 and R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	Facility to send in written plan or self certification to stay in compliance. POC due 8/25/2023 to LPA A. Canela

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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