Evergreen Retirement

At 10:00 AM, Licensing Program Analysts (LPAs) Huma Rahimi, and Nadia Shahbazian, conducted an unannounced initial complaint visit. LPAs met with the Administrator and LPAs disclosed the reason for the visit. During course of the investigation, interviews and record review were made. At 10:55 AM, LPAs requested resident and staff roster. At 12:20 PM, LPAs requested copies of pertinent information which include, but not limited to Physician's Report, Appraisal Needs and Services Plan, Admission Agreement, and etc., relevant to the investigation. At approximately 12:25 PM, LPAs conducted a physical plant tour. Between 12:45 PM to 2:00 PM, LPAs conducted an interview with the Administrator, Wellness Director (WD), three (3) Staff, and seven (7) out of ten (10) residents. Continue on LIC 9099C UnsubstantiatedRead the full finding— CDSS inspection report, November 20, 2024 · control 31-AS-20241118112448

Licensing Program Analyst (LPA) Michael Cava conducted a subsequent visit to the facility to amend the 9099D page that was issued on 03/09/24. The above allegation was investigated by Investigations Branch (IB) Investigator Spindola. IB’s investigation consisted of interviews with the facility administrator, staff, and residents. IB’s investigation also included a review of R1’s medical records from the hospital and the skilled nursing facility (SNF) that R1 was discharged to. Based on the information that IB obtained, the allegation was Substantiated, which remains the same. The purpose of amending this report is to delete the continued citation, that was entered in the Plan of Correction (POC) box, and fit into the citations box. POC has since been corrected, therefore no further corrections will be needed. Office Manager advised and a copy of this report issued. SubstantiatedRead the full finding— CDSS inspection report, September 4, 2024 · control 28-AS-20230104121616

At 9:50a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegation. LPA met with the ED and explained the reason for the visit. During initial visit on 07/28/2023 at approximately 9:15a.m., LPA conducted a physical plan walk-through, at 9:40a.m. collected facility records, included but not limited to R1 Identification and Emergency Information, Physician’s Report, Resident Appraisal, Admission Agreement and Resident Personal Property and Valuables. Between 11:20a.m. – 12:30p.m. LPA conducted interviews with three (03) out of three (03) staff and one (1) resident at the time of this visit. During Licensing Visit conducted on 05/17/2024 at 10:10a.m. LPA Alvizar-Ettima and ED conducted a physical plan tour. Between (10:30a.m – 12:30am) LPA interviewed six (6) out of seventy (70) residents. UnsubstantiatedRead the full finding— CDSS inspection report, May 17, 2024 · control 31-AS-20230727091900

At 9:50a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegations. LPA met with the ED and explained the reason for the visit. During initial visit on 07/28/2023 at approximately 9:15a.m., LPA conducted a physical plan walk-through, at 9:40a.m. collected facility records, included but not limited to R1 ,Identification and Emergency Information, Physician’s Report, Resident Appraisal, MAR’s, Unusual Incident/Injury Reports, Progress Notes and Admission Agreement. Between 11:20a.m. – 12:30p.m. LPA conducted interviews with three (03) out of three (03) staff involved with R1 care. LPA also interview one (1) resident at the time of this visit. During Licensing Visit conducted on 05/17/2024 at 10:10a.m. LPA Alvizar-Ettima and ED conducted a physical plan tour. Between (10:30a.m – 12:30am) LPA interviewed five (5) out of seventy (70) residents. Prior to this visit on 05/16/2024 LPA reviewed theRead the full finding— CDSS inspection report, May 17, 2024 · control 31-AS-20230721160221

At 9:50a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegations. LPA met with the ED and explained the reason for the visit. During initial visit on 04/10/2024 at approximately 10:30a.m., LPA request and collected facility records, included but not limited to Alternative Menu, Alternative Menu Request form, and April 2024 Menu. LPA conducted a physical plan walk-through, at 10:45a.m. Between 11:00a.m. – 1:00p.m. LPA interviewed seven (07) out of sixty-six (66) residents including resident (R1). ED and other staff were interviewed at approximately 1:10p.m. LPA asked questions relevant to the nature of the complaint. The call button was tested from seven (07) randomly selected resident's rooms and interviewed. During Licensing Visit conducted on 05/17/2024 at 10:10a.m. LPA Alvizar-Ettima and ED conducted a UnsubstantiatedRead the full finding— CDSS inspection report, May 17, 2024 · control 31-AS-20240405152252

At 12:00p.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced initial visit and was greeted by Executive Director (ED), Administrator and LPA explained the reason for the visit. During investigation at 12:05p.m. LPA requested and received staff and resident roster. At 12:15p.m. LPA and ED conducted a physical plant tour. At approximately 12:35p.m. LPA requested R1’s Resident Personal Property & Valuables and Staff Notes. Between 12:40p.m. – 1:30p.m. LPA conducted interviews with ED, Wellness Coordinator (WC), three (3) out of sixty-three (63) residents and one (1) staff that provides care to resident #1 (R1). LPA was informed that resident #2 (R2) is no longer residing at the facility therefore unable to be interviewed. UnsubstantiatedRead the full finding— CDSS inspection report, March 15, 2024 · control 31-AS-20240311161636

Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to close out the investigation regarding the above allegation. It was reported that in the morning of December 7, 2022, Resident 1 (R1) had a fall sustaining a head injury. First aid applied, but R1 was not taken to the hospital until later in the afternoon. The complaint was accepted by Investigations Branch (IB) Investigator Spindola on 01/05/23. The initial 10-day visit to this complaint was made by LPAs Cava and Gary Tan on 01/06/23. IB’s investigation consisted of interviews with the facility administrator, staff and residents. IB’s investigation also included review of R1’s medical records from the hospital and the skilled nursing facility (SNF) that R1 was discharged to. IB’s investigation revealed the following: • 01/10/23: R1 and Resident 2 (R2) has lived at the facility for approximately four years. • 01/24/23: Medical Records from the SNF revealed that R1 had a ground level faRead the full finding— CDSS inspection report, March 9, 2024 · control 28-AS-20230104121616

At 9:45a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced complaint visit to deliver the finding for the above noted allegations. At 9:55a.m. LPA met with the Executive Director and explained the reason for the visit. During initial visit on 04/24/23 at 10:16am, LPA conducted a physical plant tour, between 10:49 am – 12:30 pm LPA conducted interviews with staff involved with R1 care, and at 11:30am collected facility records, included but not limited to Professional Pest Management Invoice, Resident #1 (R1’s) Identification and Emergency Information, Physician’s Report, Resident Appraisal, and Medication Administration Records. On 02/27/2024 LPA Antonia Alvizar-Ettima reviewed the information and the documents previously obtained. During Licensing visit conducted on 03/01/2024 between 1:00p.m. -2:27p.m. LPA interviewed residents including R1. UnsubstantiatedRead the full finding— CDSS inspection report, March 6, 2024 · control 31-AS-20230418140931

At 9:45a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegation. At 9:55a.m LPA met with the Executive Director and explained the reason for the visit. During initial visit on 04/28/23 at 12:20pm, LPA conducted a physical plant check, between 12:30 pm – 2:27 pm LPA conducted interviews with staff involved with dispensing medication to R1 and R2, and at 2:50pm collected facility records, included but not limited to R1and R2 Identification and Emergency Information, Physician’s Report, Resident Appraisal, and MARs During Licensing Visit conducted on 03/01/2024 at 11:27a.m. LPA Alvizar-Ettima inspected Medication Room. Between 1:00p.m. -2:27p.m. LPA interviewed residents including R1. UnsubstantiatedRead the full finding— CDSS inspection report, March 6, 2024 · control 31-AS-20230425154440

During investigation at 9:25a.m. LPA Alvizar- Ettima and Executive Director conducted a physical plant tour. LPA Alvizar-Ettima met with Executive Director, Amber Mzczaczy and explain the reason for the visit. Between 10:15a.m. – 3:15p.m. LPA conducted interviews with six (6) out of sixty-four (64) residents, Executive Director, Administrator, Wellness Coordinator and three (3) staff. At 9:45a.m. LPA requested and reviewed medication administration documents. 1. Residents are not getting medications as prescribed It was alleged that med techs leaving medications on night stands and tables not ensuring the residents take their medications. During physical plant inspection, LPA did not notice any medications left in residents room. Staff interviews reveal that residents are getting their mediation on time and as prescribed. UnsubstantiatedRead the full finding— CDSS inspection report, March 1, 2024 · control 31-AS-20240221081352

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with the administrator, Rosio Julinek, and explained the reason for the visit. --- Staff do not serve residents food of good quality It was alleged that the facility serves food that is always cold, overcooked or undercooked and that the facility does not offer a variety of foods. To investigate the allegation, on 01/31/2024, LPA conducted a physical plant tour at 3:30 PM, requested the facility menu at around 3:45 PM, interviewed three (03) staff from 4:00 PM – 5:30 PM and interviewed six (06) residents from around 5:30 PM – 6:30 PM. During the physical plant tour, LPA observed heating lamps to keep food warm and fresh foods being prepared. A review of the facility’s menu shows that residents are provided a variety of foods each day. (CONT. on LIC 9099-C) UnsubstantiatedRead the full finding— CDSS inspection report, January 31, 2024 · control 31-AS-20240125122220

Licensing Program Analyst (LPA) Antonia Alvizar made an unannounced complaint visit to this facility. LPA was greeted by the Administrator, Rosie Julinek then Executive Director (ED) then Amber Maczaczy joined. LPA explained the purpose of the visit to ED. Staff are financially abusing residents in care. It is alleged that staff took resident debit card and made multiple unauthorized charges. To investigate this allegation, at 10:15a.m. LPA requested facility resident and staff roster. Approximately 10:40a.m. LPA and ED conducted physical plant tour. Between 10:55 a.m. and 2:00 p.m. interviewed four (04) staff, six (06) out of sixty-three (63) residents including resident #1 (R1). In addition obtained copies of R1’s Physician Report, Appraisal, Needs & Services, Unusual Incident Report, Personal Property & Valuables, and other relevant documents to the investigation. Staff revealed that R1 never provided them with a debit card and had not asked them to make a store run. R1 indicated thRead the full finding— CDSS inspection report, November 6, 2023 · control 31-AS-20231101102521

Licensing Program Analyst (LPA) Antonia Alvizar arrived at 1:00PM to the facility to conduct an unannounced complaint visit for the allegations mentioned above. LPA met with the Executive Director Amber Maczaczyj, and explained the purpose to the visit. During the course of the investigation, interviews and record review were made. At 1:05pm LPA requested copies of resident and staff roster. Approximately 1:13 pm – 3:00 pm LPA met with Culinary Director Luis Pacheco, Maintenance Arcadio Quijada, Executive Director Amber Maczaczyj, Administrator Rosie Julinek and conducted a physical plant tour. The facility Kitchen, lobby downstairs, dining room, reception desk, mailroom, activity room and three (3) randomly selected residents’ bedrooms also were inspected, and interviewed residents residing in those rooms. At 2:00pm Amber provided three (3) Service Inspection Report for Professional Pest Management to target ants, roaches and spiders. SubstantiatedRead the full finding— CDSS inspection report, October 4, 2023 · control 31-AS-20230928082746

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Rosie Julinek and explained the reason for the visit. The investigation consisted of: LPA conducted interviews with Administrator Rosie Julinek, Staff 1-4 (S1-4) and Residents 1-6 (R1-6). LPA collected copies of Staff and Resident rosters. LPA reviewed R6's facility file and collected copies of documents relevant to the investigation. (See LIC9099C for continuation) Unsubstantiated— CDSS inspection report, July 31, 2023 · control 28-AS-20220301084219

Licensing Program Analyst (LPA) Antonia Alvizar made an unannounced subsequent complaint visit to deliver finding for the above stated allegation. LPA met the Executive Director and explained the reason for the visit. LPA conducted a physical plant walk through, at approximately 10:16 am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit. It is alleged that resident #1 (R1)'s grooming needs were neglected. R#1 hair was braided and new growned of hair looked tangled. Continue on LIC9099-C UnsubstantiatedRead the full finding— CDSS inspection report, April 24, 2023 · control 28-AS-20230407144610

Licensing Program Analyst (LPA) Antonia Alvizar made an unannounced complaint visit to this facility. LPA met the Executive Director, Jonathan Perles and explained that this visit was to conduct a complete investigation of the above noted allegations. LPA conducted a physical plant tour at approximately at 10:30 am – 12:10 pm and inspected six (06) randomly selected residents bedrooms located on the 2nd and 3rd floors. During inspection, LPA Alvizar interviewed six (6) out of 65 residents including resident #1 (R1). In addition, LPA requested copies of pertinent documents relevant to the investigation at 1:30 pm. It was alleged that facility staff does not keep resident’s room clean and free of trash. Upon inspection, LPA observed the and residents’ rooms were clean and free of trash. All residents interviewed during this visit indicated that the rooms are being cleaned as required. R1 agree that housekeepers clean the room and remove trash as needed. (Continue at 9099C) UnsubstantiateRead the full finding— CDSS inspection report, March 28, 2023 · control 28-AS-20230322105426

Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director Jonathan Perles to conduct a complaint investigation, who was informed the reason of the visit. The following was determined: During today's visit, from 12pm to 330pm, LPA conducted a physical plant inspection, obtained resident records, and interviewed staff and residents. It was alleged that resident #1 (R1) inhaled and ingested hazardous chemicals. During the investigation, and information obtained, R1 fell at the facility, and the paramedics were contacted and assisted R1. R1 refused hospital services, in which R1 stayed at the facility, and was assisted by the paramedics to R1's wheelchair. R1 fell again, and allegedly observed to be under the influence of alcohol. R1 admitted to the paramedics and staff, that R1 inhaled Lysol. During interviews, it was confirmed to LPA, that R1 did ingest a hazardous chemical. This a health and safety risk to residents in care. Therefore, based on interviews, the allegatRead the full finding— CDSS inspection report, February 16, 2023 · control 28-AS-20230213105132

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Executive Director Jonathan Perles and explained the reason for the visit. LPA conducted physical plant tour at 10:00 AM, requested copies of facility documents relevant to the investigation at 10:20 AM and interviewed staff and resident between 10:30 AM to 1:00 PM. It was alleged that Resident #1 (R1)'s money was stolen sometime in December of 2022. LPA's interview today with R1 at 11:34 AM revealed that R1 could not recall the exact date and time the money was missing and unable to recall if R1 reported the incident to any staff. LPA's interview with the Executive Director at 11:15 AM also revealed that he did not receive any report of any missing money from any resident for the entire month of December 2022 and January 2023 and would have investigated it if it was reported to him. LPA's interview with the Wellness Director at 11Read the full finding— CDSS inspection report, February 1, 2023 · control 28-AS-20230126114049

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #2 (S2: Theresa Williams, Med Tech - A.M.). LPA/RA spoke to S2 prior to entering the facility to conduct a risk assessment. S2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose of today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day virtual visit was conducted by LPA Nicol Wesley on 12/24/20 (via telephone) with (former) Administrator (A1:Jonathon Isaacs). LPA/RA Ceniceros and Staff #2 toured (between 8:00 a.m. - 8:30 a.m.), the main dining room during the residents' breakfast time. LPA/RA Ceniceros interviewed (between 9:00 a.m. - 10:00 a.m.) 4 staff members and 5 residents in care. LPA/RA Ceniceros reviewed (between 10:00 a.m. - 10:30 a.m.) the requested pertinent documents for Resident #1: EmergRead the full finding— CDSS inspection report, September 29, 2022 · control 28-AS-20201215105826

*** This licensing report supersedes report delivered on 12/8/21. No changes were made to the findings*** Licensing Program Analyst (LPA) Jose Villalobos conducted a complaint investigation for the allegations listed above. LPA met with Administrator Leana Silva and discussed the purpose for todays visit. on 12/8/21,The investigation consisted of the following: LPA interviewed staff #1-#5 (S1-S5) between 11:30am-12:30pm, Toured the physical plant from 12:30-1pm , Interviewed Resident #1-#6 (R1-R6) from 1-2:30pm. LPA also reviewed the following documents from 2:30pm-3:30pm: staff roster, resident roster, R1's file, Dietitian Notes, Food Menu, and Monthly Activities menu. Resident #7 (R7) was not available to interview. On Todays visit LPA interviewed Staff#6 (S6) and facilities dietition. R7 is no longer a resident of the facility and was unable to be interviewed. The investigation revealed the following: Continued on LIC 9099-C UnsubstantiatedRead the full finding— CDSS inspection report, June 16, 2022 · control 28-AS-20211203130302