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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003773
Report Date: 11/06/2024
Date Signed: 11/06/2024 02:26:42 PM

Document Has Been Signed on 11/06/2024 02:26 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EVERGREEN CARE HOMEFACILITY NUMBER:
306003773
ADMINISTRATOR/
DIRECTOR:
HAERYUN CHOFACILITY TYPE:
740
ADDRESS:4715 ST. ANDREWS AVENUETELEPHONE:
(562) 480-9453
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 6DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:53 AM
MET WITH:Haeryun ChoTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Samer Haddaddin arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by staff. LPAs met with Haeryun Cho, Administrator and explained the purpose of the inspection.

The facility is two-story home. Per facility staff, residents do not go upstairs, as the facility owners reside upstairs. The first floor houses with four resident bedrooms, three resident bathrooms, kitchen, dining room, living room, attached 2-car garage and backyard. The second floor houses a bedroom, two bathrooms and a den. Facility appears clean, safe and sanitary. LPA observed the facility has the necessary postings posted on the walls. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. LPAs observed one resident's bed has full bed rails. AD could not provide a physician's order for the bed rails. A deficiency is being issued. Facility has extra linens and hygiene supplies for residents in hallway cabinets. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured 107.2, 108.3 and 109.2 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was purchased on 11/10/2023 according to the attached receipt.


Smoke/Carbon Monoxide detector were tested and noted as operational. LPAs observed the drawer for the knives was unlocked. AD stated they could not find the key. A deficiency is being issued. Medication for each resident is kept locked in a cabinet in the dining area. LPAs observed exit gate to be unobstructed. LPAs reviewed six resident files and three staff files. LPAs also reviewed medication for three residents. Based on record review, LPAs determined, facility does not have health screenings for 2 staff members. A deficiency is being issued. Based on record review, LPAs determined the facility does not have a disaster drill log. A deficiency is being issued.

Based on today's inspection, four citations are being issued. An exit interview was conducted and a copy of this report, deficiency pages, Component III presentation and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 4
Document Has Been Signed on 11/06/2024 02:26 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 11/06/2024 at 01:24 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EVERGREEN CARE HOME

FACILITY NUMBER: 306003773

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to the knife drawer being unlocked. The AD also stated they did not know where the key was. This poses an immediate safety risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Administrator stated they will get a new key made for the drawer. AD stated they will conduct an in-service training with facility staff. AD stated they will document the following: 1. Participating staff, 2. Date/Time, 3. Topic covered in training. AD stated they will email LPA the document regarding this training by Close of Business on the assigned POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/06/2024 02:26 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 11/06/2024 at 01:24 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EVERGREEN CARE HOME

FACILITY NUMBER: 306003773

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Administrator stated they will obtain completed health screenings for facility staff and send them to LPA via email by the assigned POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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
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Based on record review and interview, the licensee did not comply with the section cited above due to not being able to present a disaster drill log.This poses a potential safety risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Administrator stated they will conduct a drill and document the folllowing: 1. Participating staff, 2. Date/Time of the drill 3. Type of drill conducted 4. Participating residents. AD stated they will send the record created to LPA via email by the assigned POC due 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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/06/2024 02:26 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 11/06/2024 at 01:24 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EVERGREEN CARE HOME

FACILITY NUMBER: 306003773

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 6 resident beds.This poses a potential safety or personal rights risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Administrator stated they will remove the bed rails from the beds, take photos of both sides of both beds and send them LPA via email by the assigned POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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