Evergreen Senior Home Care

Type of visit: Required - 1 Year

On 9/16/2026 at 11:30 AM, Licensing Program Analyst (LPA) Matthew Aguilar made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Administrator Tamana Rahmanand was granted entry to the facility. At the time of the visit there were three (3) staff present, and six (6) residents present. The facility has six (6) bedrooms, three (3) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for six (6) non ambulatory residents, of which one (1) may be bedridden in bedroom #6 (six). The facility has six (6) hospice care waivers, and the current census is six (6) residents. The facility is also licensed to care for residents with dementia. LPA was accompanied by a staff to conduct a general overall inspection, which included, but was not limited to the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with the required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperatures in the bathroom to be at 115 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguisher was also observed at the facility. Posters such as personal rights, the CCLD complaint poster, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine closet with the resident’s medications locked. LPAs observed first aid kit and first aid book at the facility. Yards/Outside: One shaded patio with a backyard garden, two (2) side pathways on the right side and left side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions. Food Service: Seven (7) days’ supply of Non-perishable foods and two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. LPA observed that the facility has sufficient 72 hour emergency food and water. Care & Supervision: The facility has an Administrator present in the facility with enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. The facility is licensed for one (1) bedbound resident in bedroom #6. Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA observed resident files reviewed were complete. LPA reviewed six (6) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed staff files are complete. LPA observed that the facility completed quarterly fire and earthquake drills. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC809 was discussed and provided to Administrator Tamana Rahman.the state’s words, verbatim · CDSS document, Sep 16, 2026

Allegation investigated: Staff are violating residents personal rights. Staff does not ensure resident's room is free of odor. Staff denied privacy with resident visitor.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegations listed above. LPA met with Administrator Tamanna Rahman and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, and facility tour. For the allegation, staff are violating residents personal rights. During staff interviews, 4 out of 4 staff members stated they have not violated residents’ personal rights. During resident interviews, 2 out of 3 residents stated their personal rights have not been violated. In addition, 1 out of 3 residents was unable to corroborate the allegation. For the allegation, staff do not ensure resident’s rooms is free of odor. During staff interviews, 4 out of 4 staff members stated they ensure residents’ rooms are kept free of odor. During the facility tour, LPA observed that residents’ rooms were free of odor. Unsubstantiated For the allegation, staff denied privacy with resident visitors. During staff interviews, 4 out of 4 staff members stated they ensure residents are provided privacy and the ability to have private conversations with their visitors. During resident interviews, 2 out of 3 residents stated they are allowed to have privacy with their visitors. In addition, 1 out of 3 residents was unable to corroborate the allegation. Based on the evidence found during the investigation, the (3) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Tamanna Rahman.the state’s words, verbatim · CDSS document, Jan 2, 2026 · control 56-AS-20251119190218

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Mary Rico conducted an announced visit to complete a pre-licensing inspection and component III. LPA met with Licensee/Administrator Tamanna Rahman. The pending application is for a change of ownership for a Residential Care Facility for the Elderly (RCFE). The approved fire clearance granted for four (5) non-ambulatory and one (1) bed-ridden residents on 2/25/2025. The interior and exterior were toured of the pending facility. Overall, the pending facility is clean and in good condition. LPA observed all bedrooms to be appropriately furnished with adequate lighting. Bathroom toilets, showers have grab bars and non-skid mats. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. All appliances are clean and operating properly. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present including a First Aid Manual. LPA observed an adequate supply of recreation and leisure items and activities. Outdoor space is suitable for resident use that includes a covered patio with a table and chairs. LPA observed the fire extinguishers to be recently serviced and completely charged. Smoke alarms and carbon monoxide detectors are present and functional. Medications will be centrally stored and secured in a locked space. All hazardous materials such as, cleaning, and disinfecting supplies, knives and other sharps are locked and inaccessible to residents. All required forms are posted in a common area. Pre-Licensing Inspection is complete and has no deficiencies. No corrections need to be made. An exit interview was conducted where this report was discussed and provided to Licensee/Administrator Tamanna Rahman.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Licensee/administrator TAMANNA RAHMAN and Licensee Tawsique Salam Interview Method: Telephone interview On 7/10/2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. 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, Jul 10, 2025