EVERGREEN RESIDENCE

Official classification

Type B

Official code

87208(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (2) A copy of the Admission Agreement, containing basic and optional services. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 4 residents has a missing Admission Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2025 Plan of Correction Licensee agrees to have a complete Admission Agreement for R1 and submit to CCLD by POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 facility fire drill is missing which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2025 Plan of Correction Licensee agrees to complete a fire drill in the facility and submit the completed document to CCLD by POC due date.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Personnel Records/Staff Training - Type B: 87412(a)(11) - 1 out of 5 staff is missing LIC-503 with the TB test. Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 4 staff is missing an LIC-503 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2025 Plan of Correction Licensee agrees to have staff visit Physician and have a completed LIC-503 with TB and submit to CCLD by POC due date.

Official classification

Type A

Official code

87555(b)(29)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one out of one; LPA observed the Ice machine with possible black like mold which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/09/2024 Plan of Correction Licensee agrees to drain and empty the ice machine and do a deep clean before using and submit pictures of the ice machine of proof of cleaning by due 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, the licensee did not comply with the section cited above in 1 out of 1; LPA observed unlocked medication pills without a label, Eye drops and Hydrogen Peroxide in a cabinet in the dining area which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/09/2024 Plan of Correction Administrator removed and locked the medications during inspection. Administrator agrees to provide in-service training for medication storage and submit records when completed.

Official classification

Type A

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 residents Medical assessments were over a year old, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/09/2024 Plan of Correction Administrator agrees to schedule appointments and show documentation of scheduling for new medical assessments. Once new medical assessments are received Administrator will submit copies to CCLD.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 residents medication pill count was observed to have 8 pills extra. Staff admitted to transferring medication from old bottle to new bottle, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/09/2024 Plan of Correction Administrator agrees to submit a statement of intent to provide in-service training for all medication techs regarding medication regulations by due date. Administrator agrees do a spot audit for next month to ensure issues are not recurring.

Official classification

Type A

Official code

87303(a)(1)

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 2. Based on interview with staff; Laundry room door was proped open due to it getting jammed. Tile in the memory shower was chipped which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction Based on interview laundry room door has been repaired. Licnesee to repair/replace broken tile and submit pictures and invoice once repair. Licensee to schedule repair and submit documentation to CCLD by date.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 3 out of 3 bedroom water temperature tested. Two rooms in memeory care water tested at 126.2 and 132.5. One room tested in AL side 104.8 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction Licensee to adjust water heater temperatures between 105 to 120. LPA will retest water heater temperatures at a later date.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 out of 2 water tested at 126.2 and 132.5 and did not have warning signs which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction Licensee to test all room water temperatures and place warning signs on Taps delivering water at 125 degree F (52 degrees C) or above

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 1 out of disinfectants, bleach and laundry soap was accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction Laundry door has been repair. POC during inspection.

Official classification

Type A

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 1 out of 1; Expired food observed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction Licnesee to go through all food and remove expired food and ensure food is checked periodically to remove expired items

Official classification

Type A

Official code

87555(b)(29)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 1 out of 1; Ice Machine observed to have brown buildup underneath the door lift area.which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction Licnesee to ensure deep cleaning of ice machine and submit pictures to CCLD by due date

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 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 is not met as evidenced by: LPA observed Bleach and Laundry detergent in the laundry room and unlocked chemicals and cleaning supplies in the dinning room cabinet.

Official plan of correction

Administrator had staff lock laundry room door. Chemicals in Memory care storage were removed and placed in locked area. Administrator to complete an in-service training with all staff in regards to locking disinfectants, cleaning solutions and submit to CCLD by due date.

Deadline recorded: Sep 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, LPA and Administrator Assistant observed five out of six Fire Extinguisher serviced date expired: Fire Extinguisher 1 has a service date of 8/02/2021, Fire Extinguisher 3 serviced date of 08/02/2021, Fire Extinguisher 4 serviced date 08/02/2021, Fire Extinguisher 6 serviced date of 08/27/2020, Fire Extinguisher 7 serviced date of 08/02/2021 which poses an immediate health and safety risk to the residents.

Official plan of correction

POC Due Date: 10/05/2022 Plan of Correction Licensee shall submit proof of fire extinguisher replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 10/05/22.

Official classification

Type B

Official code

87303(i)(1)(A)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not have a signal system available for each resident in each room which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/04/2021 Plan of Correction The licensee agrees to put a signal systems in each room for each residents to utilizes by POC due date.