EVERGREEN RETIREMENT

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466: Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.This requirement is not met as evidenced by: Based on the interviews conducted and record reviews, Licensee did not document that R1 obtained medical professional assistance for behavior observed which poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

The administrator agreed to certify in writing that upon observing changes in condition or behaviors in the residents, will provide assistance with obtaining proper medical care and submit a letter to the department by POC date.

Deadline recorded: Jul 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

03

Regulation authority

CCR

What the official deficiency says

Eviction Procedures: 87224 (d) - The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. Based on interviews and record review, facility did not comply with providing R1 with an lawful eviction notice with specific reasons/dates, which poses/posed an immediate health, safety to persons in care

Official plan of correction

Administrator has allowed R1 to stay in the facility, since R1 was placed on notice and has not had behavioral outbursts recently. Staff will continue to provide assistance to R1 for behaviors and update the Appraisal/Needs and Care plan. Administrator may submit a new eviction notice, along with behavioral reassessement, in the future. POC cleared during today's visit.

Deadline recorded: Mar 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for ... medication ... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met by: Based on interviews and record review, facility did not comply with physician orders regarding R1's medication, which poses/posed an immediate health, safety to persons in care

Official plan of correction

Administrator removed S2 from their role as a Med Tech and assigned S2 to a Caregiver position. In addition Med Staff were retrained in medication administration process. POC cleared on the date of visit.

Deadline recorded: Dec 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 Based on interviews and observations, the licensee did not comply with the section cited above. R1's room was not clean and full of clutter which poses/possessed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Executive director will conducted in service training to all staff regarding the cited section and will provide list of attendees.

Deadline recorded: Sep 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 Based on interviews and observations, the licensee did not comply with the section cited above. R1's room was not clean and full of clutter which poses/possessed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Executive director will conducted in service training to all staff regarding the cited section and will provide list of attendees.

Deadline recorded: Sep 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(b)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. This requirement was not met. Based on interviews, the licensee did not comply with the section cited above. Interviews with 5 out of 72 residents stated that room temperature is not comfortable and it gets extremely cold which poses a potential personal rights risk to persons in care.

Official plan of correction

Executive Director measure all residents room temperature and have the AC system adjusted to the appropriate range and will maintain daily temperature log. A copy of the log and a picture of adjusted AC system will be sent to LPA by the POC date.

Deadline recorded: Aug 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87218(1)

Regulation authority

CCR

What the official deficiency says

87218 Theft and Loss (1)The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. This requirement was not met. Based on record reviews, the licensee did not comply with the section cited above. R1's Resident Personal Property and Valuables form (LIC 621) and it was not complete. which poses a potential personal rights risk to persons in care.

Official plan of correction

Executive Director will complete Resident Personal Property and Valuables form (LIC 621) for all the current residents by the POC date.

Deadline recorded: Aug 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

Administrator-Qualifications and Duties: The Administrator shall have the knowledge of the requirements for providing care and supervision..The administrator shall also have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on observations and records review the Administrator did non comply with the section sited above by not following the Addmission Agreement regarding the smoking house rules.

Official plan of correction

The administrator will issue letters regarding house rules to prohibit smoking in suites and all common areas, both inside and outside the building. A copy of the letters will be emailed to LPA by the POC date.

Deadline recorded: Mar 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(a)(3)

Regulation authority

CCR

What the official deficiency says

Reappraisals- In Part: (a) Pre-admission appraisal shall be updated as necessary…to note significant changes & keep appraisal accurate. Significant changes include: (3) Any illness or change in health care needs of the resident. This requirement was not met as evidenced by: Based on LPA’s review of R1’s medical records which document since 10/22/22 staff had knowledge of R1’s cognitive/physical decline & increased needs for service. This deficiency posed an immediate health and safety risk to the resident in care.

Official plan of correction

The licensee has since submitted their POC, which was cleared on 03/18/24. No further corrections required.

Deadline recorded: Sep 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental and Medical Dental Care- The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis This requirement was not met as evidenced by, R1 experienced a fall, suffered a head injury, and was found on a pool blood in the morning of 12/07/22. R1 was not sent to the hospital until the afternoon of that date. This poses an immediate health and safety risk to the resident in care.

Official plan of correction

As POC, administrator will hold staff training to address this section of the regulations. As proof POC was completed, administrator will submit attendance log and training topic to the licensing agency by 03/18/24.

Deadline recorded: Mar 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(a)(3)

Regulation authority

CCR

What the official deficiency says

Reappraisals- The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: Any illness, injury, trauma, or change in the health care needs of the resident. This requirement was not met as evidence by: a review of R1’s medical records indicate that since October 22, 2022, facility staff had knowledge of R1’s cognitive and physical condition progressing

Official plan of correction

Cont. continued to decline, and required assistance with hydration to prevent an infectious disease (sepsis), which caused R1’s brain to malfunction and experience a dysfunction that altered consciousness and behavior. This posed an immediate health and safety risk to the resident in care. As POC, administrator will hold staff training to address this section of the regulations. As proof POC was completed, administrator will submit attendance log and training topic to the licensing agency by 03/18/24.

Deadline recorded: Mar 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87455(c)(3)(B)

Regulation authority

CCR

What the official deficiency says

Acceptance and Retention Limitations- No resident shall be accepted or retained if any of the following apply: Dementia, unless the requirements of Section 87705, Care of Persons with Dementia, are met. This requirement was not met as evidenced by: a review of R1’s records indicate that R1 began to express behaviors and symptoms of dementia. Staff was aware of this decline, but failed to accurately assess R1 in order to meet their needs. This posed an immediate health and safety risk to the resident in care.

Official plan of correction

As POC, administrator will hold staff training to address this section of the regulations. As proof POC was completed, administrator will submit attendance log and training topic to the licensing agency by 03/18/24.

Deadline recorded: Mar 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) The facility shall be clean, safe, sanitary... 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: Based on inspection, and observation the Licensee did not ensure that the facility is safe and sanitary for wellbeing of residents and others. LPA observed rodent droppings in food storage/office, kitchen and reception desk. This poses a potential health, safety risk and personal rights violation to residents in care.

Official plan of correction

The Administrator will take all measures to maintain the facility free from rodents. Administrator will submit updated documentation of Pest Control service agreement to LPA via fax by POC due date.

Deadline recorded: Oct 18, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80076(a)(17)

Regulation authority

CCR

What the official deficiency says

80076(a)(17) Food Service. Kitchens, food preparation, and storage areas shall be kept clean... free of rodents, and other vermin. This requirement is not met as evidenced by: Based on inspection, and observation the Licensee did not ensure that the kitchen was free from rodents. LPA observed rodent droppings in storage room/office on metal shelf, containers, boxes, food tin cans, food bags and underneath kitchen sink. This poses a potential health, safety risk and personal rights violation to residents in care.

Official plan of correction

The Administrator will instruct staff to cover holes on the wall to maintain the kitchen free from rodents. Staff will keep kichen clean at all times. Adminstrator will submit updated documentation of Pest Control service agreement to LPA via fax by POC due date.

Deadline recorded: Oct 18, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met evidenced by, during today's visit, it was revealed that resident # 1(R1) inhaled Lysol. This is immediate health and safety risk to residents in care.

Official plan of correction

Executive Director (ED) has AGREED to in writing, via email, by the POC date to LPA, how the facility is going to ensure how they plan to keep chemicals secured for residents. ED may request for more time to correct the POC, once LPA has received the plan in writing.

Deadline recorded: Feb 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, some resident rooms did not have soap, paper towles or sanitizer. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/16/2022 Plan of Correction Licensee will provide paper towles, soap and sanitizer in every room, provide in service on infection control, send signed roster of staff that attended in service and self certify when completed and send proof to LPA by POC date,

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) 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 met as evidenced by: Deficient Practice Statement Based on observation, PRN medication for one resident was not centrally stored which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2022 Plan of Correction Staff will removed the PRN medication from resident room and provide proof to LPA by POC date. ***Corrected during visit and no further action is required.****

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 Based on observation LPA and Sales Director Tahni Harp observed broken glass on fire extinguisher compartment and electrical doors in disrepair. Also Window in room 308 does not stay open on its own and wall in front of that window is in disrepair. Wall by tub in room 210 has water damage from possible leak which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2022 Plan of Correction Licensse will replace broken glass on fire extinguisher compartment and repair/replace the electrical doors, repair bathroom window in room 308 and paint wall by window in room 308 behind towel rack, Repair wall with water damage in room 210 and provide proof of repair to LPA by POC date. ***Glass on Fire extinguisher compartment was replaced during visit***

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation shower facet in room 208 needs replacement or repair. Sink in room 308 does not drain properly which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2022 Plan of Correction Licensee will repair/replace facet in room 208 and repair sink drain in room 308 and send LPA proof by POC Date.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, LPA and Sales Director Tahni Harp obseerved 2 water tanks, a loose door and plastic sheeting obstructing passageway which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2022 Plan of Correction Licensse will remove the items obstructing passageways and send photos as evidence to LPA by POC date. ****obstructions were removed during visit and no further action is required****