Evelyn's Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sakinah Madyun conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA Madyun was met by Administrator Kaylon Hallman approximately 2:30 PM and explained reason for visit. The facility is licensed for residents between the ages range 60 and over, six (6) non-ambulatory, room #4 approved for 1 bedridden, and hospice waiver for three (3). The facility is a single-story home located in a residential neighborhood. It consists of four (4) resident bedrooms in which room #2 and room # 3 are shared, two (2) bathrooms, a living room/dining room, a kitchen, a front and back patio area, a laundry area, and a detached garage that stores additional supplies. LPA toured the facility and observed the following: Physical Plant & Environmental: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway cabinet. Smoke detectors and carbon monoxide detectors were observed in each room and throughout the facility and are properly operating. The facility has one (1) fully charged fire extinguisher which is located in the kitchen. Cleaning supplies and toxic substances are inaccessible to residents in care and securely locked and stored in kitchen cabinet and storage. The freezer is maintained at a temperature of 0-degree Fahrenheit and the refrigerator at a maximum of 45 degrees Fahrenheit. LPA observed a sufficient supply of 2 days perishable & 7 days non-perishable foods in the kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms and kitchen measured between the required range of 105-120 degrees Fahrenheit. There is a shaded seating area for the residents located in the backyard. The facility does not have a swimming pool or bodies of water on the premises. The passageways and exits are free of obstruction. Continued LIC 809C LPA observed Emergency Fire and Earthquake Drills Log recorded drills were conducted monthly and now quarterly with the last drill conducted 11/30/25. Staff Personnel Files: Due to time constraint LPA will return for continuation visit at a later date and time to review staff files and training logs and conduct staff interviews. Client Files: Due to time constraint LPA will return for continuation visit at a later date and time to review client files and medication logs.. Infection Control Plan: First-aid kit was fully stocked and centrally stored locked in the kitchen medicine cabinet. LPA observed the Infection Control Plan revised 06/01/25 and Emergency Disaster Plan revised 06/01/25. Due to time constraint LPA will return at a later date and time for a continuation visit. Exit interview was conducted with Administrator Kaylon Hallman and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 15, 2026

Allegation investigated: Staff are not ensuring that resident is administered their medications as necessary.

Licensing Program Analyst (LPA) Daniel Konishi conducted an initial 10-day complaint visit in regards to the allegation listed above. LPA explained the purpose of the visit to Kaylon Hallman, the Administrator for the facility that assisted with the visit. The investigation consisted of the following: LPA obtained copies of Staff Roster, Resident Roster, Weekly Menu, Diabetic Meal Plan. and Resident #1 (R1) files such as: Physician’s Report, Daily Shower Logs (July 2025), Medication Administration Record (July 2025). LPA toured the facility's kitchen. LPA interviewed the Assistant Administrator, Staff #1 (S1) and Former Resident #1 (FR1), Resident # 1 (R1), and Resident #2 (R2). The investigation revealed the following: in regards to the allegation “Staff are not ensuring that resident is administered their medications as necessary.” It is alleged that staff did not provide FR1 medication for three days to help manage hypertension and diabetes. Substantiated Based on interview, FR1 corroborated with the allegation and stated on not receiving medication for hypertension to manage his blood pressure from the staff for three to four days while living at the facility. Based on resident interview, one (1) out of two (2) residents denied the allegation and stated on receiving medications as prescribed and had no issues. One (1) out of two (2) residents stated being independent and medication management is not needed from the facility. The Administrator and S1 denied the allegation stating that medication have been provided to FR1 as prescribed. However, based on record review, LPA observed that on the Medication Administration Record for the month of July 2025 provided by the Administrator, FR1’s Metformin 1000MG of 1 tablet 2 times daily, the medication to be taken at 8pm from July 18, 2025, to July 22, 2025, was not initialed by staff. The Administrator stated that the Medication Administration Record provided was due to an error and also stated that there’s another Medication Administration Record that shows that that medication was provided on those dates. LPA requested to see that document. However, the Administrator did not provide the document to confirm that Metformin was given on the date of July 18, 2025, to July 22, 2025, at 8pm during the visit. Therefore, there was sufficient supportive evidence to concur with the reported allegation. Based on LPA's interviews conducted with the residents and staff, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099D. An exit interview was held with the Administrator, Kaylon Hallman, and a copy of this report and appeal rights were provided. Based on interview, the FR1 corroborated with the allegation stating that the facility only provided the same one meal consisting of sausage. Based on resident interview, two (2) out of (2) residents denied the allegations stating that three meals are provided daily and that there are provided a variety of meals and also mentioned that there was not a time where they were served only sausage or only one meal daily. Based on staff interview, the Administrator and S1 denied the allegation stating that three meals are provided daily. Based on record review, LPA reviewed the facility’s weekly menu which shows three daily meals are provided with a variety of protein such as chicken, beef, and fish. Based on observation, the facility has sufficient food supply including a minimum of 2 days perishable and 7 days non-perishable. The facility kitchen is clean and well-kept and in a operable condition. The food are properly stored in the refrigerator to avoid cross contamination. The freezer had a variety of protein such as chicken, beef, and microwaveable meals. Per Administrator, there are no residents who requires a modified diet that's prescribed by the doctor. There is not enough supportive evidence to concur with the reported allegation. Allegation: “Staff do not ensure resident hygiene needs are met.” It is alleged that the staff are not providing residents showers. Based on resident interview, FR1 and one (1) out of two (2) residents denied the allegation stating that the facility staff did help provide assistance with showers. One (1) out of two (2) residents stated being able to independently take showers and not needing any staff assistance. Two (2) out of two (2) residents also stated not witnessing nor have any concerns of any residents’ hygiene not being met. The Administrator and S1 denied the allegation stating that they provided shower assistance for FR1 when FR1 resided at the facility. Based on record review, LPA reviewed FR1’s daily shower logs from July 18th, 2025, to July 31st, 2025, and showers were provided by 8am. The Administrator and S1 also stated that they continue to provide daily shower assistance at the facility. There is not enough supportive evidence to concur with the reported allegation. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was held, and a copy of this report was provided to the Administrator, Kaylon Hallman.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 28-AS-20250731140624

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 8, 2025

87465 (a)(4) Licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview and record review, LPA observed MARs (Medication Administration Record) for FR1 was missing initials for Metformin 1,000MG of 1 tablet at 8pm from July 18th, 2025, to July 22nd, 2025, and that Former Resident #1 (FR1) stated not receiving medication for hypertension for three to four days which poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: The administrator will submit a plan on re-training the staff on medication management and will retrain staff that pass out medications and will submit training materials and sign in sheets discussed by the POC due date. Daniel.Konishi@dss.ca.gov

Allegation investigated: Staff did not ensure medications were dispensed and prescribed to resident in care. Staff did not inventory residents medications upon entry to the facility.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegations. LPA met with Kaylon Hallman, Administrator and explained the purpose of the visit. The investigation consisted of the following: LPA obtained copies of the staff & resident rosters, training logs for S1-S2's medication training, and Resident #1 (R1) pertinent files such as: Identification/Emergency Information and Kaiser Medical assessment. Administrator cannot provide copies of any other files for R1 and no incident reports submitted. LPA interviewed Staff #1 (S1) - Staff #2 (S2) and Resident #2 (R2). Residence #1 (R1) has moved out and in the hospital, therefore not interviewed. LPA attempted to interview Resident #3 (R3) - Resident #4 (R4), but unsuccessful due to their cognitive abilities. *****CONTINUED ON LIC9099-C***** Substantiated The investigation revealed the following: In regards to the allegation: “Staff did not ensure medications were dispensed and prescribed to resident in care.” It is alleged that upon the resident’s temporary placement in the facility on 6/26/2025, staff missed giving a resident their medication for a full day and failed to ensure that the resident received it. Interview with S1 revealed that medication for R1 was not administered as per the doctors’ orders because S1 failed to properly assess R1 prior to R1's transfer to the facility. Additionally, the paramedics who brought R1 into the facility did not give S1 any documents for R1, nor did they inform him about any medications R1 was taking. Due to this, S1 did not have a record of R1's current prescribed medications. S2 stated that she has not administered medications to any of the (3) current residents in the facility. Interview with R2 revealed that they do not take medications. LPA unsuccessfully interviewed R1 as they moved out of the facility on 6/27/2025 and is now in the hospital. LPA confirmed that an incident/injury report (SIR) was not submitted for this incident. The lack of documentation and interviews conducted corroborate this allegation. In regards to the allegation: “Staff did not inventory residents medications upon entry to the facility.” It is alleged that upon the resident’s temporary placement in the facility on 6/26/2025, the resident’s medication was left in the bag on the floor of the room and staff never checked the bag to check their medications. Interview with S1 revealed that the paramedics brought R1 to the facility on the evening of June 26, 2025. S1 stated that the paramedics did not give S1 any documents for R1, nor did they inform him about any medications R1 was taking. S1 indicated that R1 came in with bags of dirty clothes and inside the bag were R1's medications. However, S1 also stated that paramedics advised S1 to be cautious when handling R1 because of R1's medical condition that might be contagious while taking antibiotics. For this reason, S1 did not take an inventory of R1's belongings. Interview with R2 revealed that they could not recall whether their personal items were inventoried by the staff when they moved. LPA unsuccessfully interviewed R1 as they moved out of the facility on 6/27/2025 and is now in the hospital. LPA confirmed that an incident/injury report (SIR) was not submitted for this incident. The lack of documentation and interviews conducted corroborate this allegation. Based on LPA’s interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Administrator, Kaylon Hallman along with the Appeals Rights.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 28-AS-20250723090756

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458)a)(3) · Plan of correction due date: Aug 5, 2025

87458 Medical Assessment ..(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment...in the resident's record.(3) A record of current prescribed medications.... This requirement is not met as evidenced by: Based on interviews, records review, the licensee did not comply with the section cited above in which Administrator failed to assess R1 and did not obtain documentation of a medical assessment prior to accepting R1 as a resident which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator agreed to develop an outline of a written plan to ensure the requirements of this regulation are met and self certify that he read, reviewed and understood Title 22 Regs. 87458 and submit plan/certification to CCL/LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jul 29, 2025

87465 ..Incidental Medical and Dental Care..(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical..and provide for assistance in obtaining such care...(6) When requested by the Department, a record of dosages of medications...shall be maintained... This requirement is not met as evidenced by: Based on interviews, records review, the licensee did not comply with the section cited above in which Administrator failed to inventory medications and maintain these required records. which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Administrator agreed to develop a written plan for maintaining medication records and record keeping practices upon admission of residents. Administrator to self certify that he read, reviewed and understood Title 22 Regulation 87465 and submit plan/certification to CCL/LPA by POC due date.

Type of visit: Prelicensing

LPA Gutierrez made a follow up visit to the pre-licensing conducted on 02/06/2025. During the visit LPA observed working telephone, CPR/First Aid Manual, and Complaint poster PUB 475. No outstanding or pending items were observed. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation. Exit interview held and a copy of the report was provided to applicant Kaylon Hallman.the state’s words, verbatim · CDSS document, Feb 11, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Christian Gutierrez conducted a pre-licensing visit. LPA met with applicant Kaylon Hallman. An initial application was submitted to Community Care Licensing Department (CCLD) for a Residential Care Facility for the Elderly (RCFE) to serve 6 non-ambulatory residents in the age range of 60 and over. The fire clearance has been approved for six (6) non-ambulatory residents with one being bedridden in room #4. This property has never been licensed. The physical plant was toured with the applicant. Component III was conducted. The facility is in a residential area and is a one-story family home. There are four (4) resident bedrooms, two (2) bathrooms, living room, dining area, kitchen, front yard, back yard, and detached garage with office. LPA conducted the tour with Kaylon Hallman and observed the following: Smoke detectors were observed in common areas and in each resident’s bedroom. There are 2 carbon monoxide detectors in hallway. Residents’ bedrooms were observed to have required furniture such as bed frames, dressers, chairs, lamps, and sufficient closet space. The required bedding was also observed. The home has two (2) bathrooms and were clean and sanitary. The water temperate was tested and measured at 108.1 and 105.6 degrees, which is within the required 105-120 degrees. Grab bars and non-slip mats were also observed in bathrooms. There is a fire extinguisher in kitchen. All appliances in kitchen were observed to be clean and operational. The sharp knives are located in the kitchen drawer that is inaccessible to residents. Cleaning supplies and chemicals are stored in a locked cabinet under sink. Medications will be locked in a cabinet in kitchen. The backyard has a shaded area for residents. The home does not have a pool or any large bodies of water. There are cameras only in common areas inside the home. No records were reviewed since the home has never been licensed. SEE LIC 809 C The following discrepancies were observed and must be corrected. #1 Facility will obtain telephone for residents. #2 Complaint poster PUB 475 will be posted. #3 Facility will obtain first aid manual. An exit interview was conducted. A copy of this report was given to Kaylon Hallman.the state’s words, verbatim · CDSS document, Feb 6, 2025

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 Method: Telephone call with CAB COMP II Participants: Kaylon Hallman, Administrator/Owner; Shannon Betker, analyst. Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jan 22, 2025