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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609022
Report Date: 06/09/2022
Date Signed: 06/09/2022 04:55:35 PM

Document Has Been Signed on 06/09/2022 04:55 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EVERGREEN RETIREMENTFACILITY NUMBER:
197609022
ADMINISTRATOR:ROSIO JULINEKFACILITY TYPE:
740
ADDRESS:225 NORTH EVERGREEN STREETTELEPHONE:
(818) 843-8268
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 99CENSUS: 55DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Execuitve Director Leana Silva TIME COMPLETED:
05:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Sales and Marketing Director Tahni Harp and explained the purpose of the visit. Executive Director Leana Silva showed up a little later and assisted with the inspection. Sandra Albarron, Regional Wellness joined in the inspection The facility does not have a Dementia waiver. A hospice waiver for 6 residents is in place. Facility is a 3-story building consisting of 72 resident rooms, 2 common areas, 1 living room/activity room, dining room, kitchen, 2 laundry rooms, and a courtyard patio area. The facility's last fire inspection was conducted on 03/21/2022. The following was inspected and observed during the inspection:

· The facility main entrance does have required COVID-19 signs posted at the entrance.
· Visitors are screened at the main entrance and a log is kept.
· Signs are not posted throughout the facility in common areas, hallways, and public restrooms to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has single-person isolation rooms.
· Twelve (9) resident rooms were inspected. None of the rooms, (9) resident rooms did not have alcohol based hand sanitizer. Rooms 329 and 206 did not have soap, paper towels or sanitizer. Room 208 did not have soap. Room 210 had no paper towels and sanitizer
· Room 308 bathroom sick does not drain properly, wall by grab bar needs painting and window repair.
· Fire extinguisher by room by 210 needs broken glass replaced.
· Room 210 the wall has water damage and needs to be repaired. Shower facet needs repair or replacement.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 06/09/2022 04:55 PM - It Cannot Be Edited


Created By: Alberto Lopez On 06/09/2022 at 03:35 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(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
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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.
POC Due Date: 06/16/2022
Plan of Correction
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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,
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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
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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.
POC Due Date: 06/09/2022
Plan of Correction
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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.****
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/09/2022 04:55 PM - It Cannot Be Edited


Created By: Alberto Lopez On 06/09/2022 at 03:35 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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
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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.
POC Due Date: 06/30/2022
Plan of Correction
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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***
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(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
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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.
POC Due Date: 06/30/2022
Plan of Correction
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Licensee will repair/replace facet in room 208 and repair sink drain in room 308 and send LPA proof by POC Date.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/09/2022 04:55 PM - It Cannot Be Edited


Created By: Alberto Lopez On 06/09/2022 at 03:35 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(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
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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.
POC Due Date: 06/09/2022
Plan of Correction
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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****
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EVERGREEN RETIREMENT
FACILITY NUMBER: 197609022
VISIT DATE: 06/09/2022
NARRATIVE
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· 2nd floor sanitizer dispenser by elevator was empty.
· Gate by smoking area does not lock. Also 2 blue water storage tanks, a door and other debris needs to be removed.
· Electrical door needs to be replaced or repaired.
· Six (4) centrally stored resident medication records were reviewed.
· One resident had his medication in his room he shares with spouse and can administer own medication, however, Spouse is unable to administer medication and medication should me in lock box or removed.
· The majority residents walking or lounging in common areas were not observed wearing masks but adhering to social distancing guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. Lunch dining service was observed. All residents were socially distanced according to local public health guidelines.

Deficiencies were cited. See LIC809D.

Exit interview was conducted with Executive Director Leana Silva A copy of the report and appeal rights were issued.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
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