Evergreen Care Home

Type of visit: POC

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility for the purpose of conducting a plan of correction (POC) visit for deficiencies issued during the annual inspection on November 4, 2025. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Haeryun Cho and discussed the purpose of the visit. LPA toured the facility to inspect that the deficiencies have been corrected with AD. LPA observed that the stove burners turn on without a lighter and are operational. Thus, clearing Type B deficiency CCR 87303(a). AD informed LPA that the staff file that needed to be updated for the POC was no longer employed at the facility. LPA observed current staff files and observed them to have a health screening and TB test. Thus, clearing Type B deficiency CCR 87412(a)(11). LPA observed updated annual staff training completed in the current staff files as the staff file observed during the annual inspection no longer is employed at the facility. Thus, clearing Type B deficiency HSC 1569.625(b)(2). Based on observations made during today’s visit, all Plan of Corrections have been fulfilled by the assigned POC due date of November 25, 2025. An exit interview was conducted and a copy of this report and clearance letters were left at the facility.the state’s words, verbatim · CDSS document, Dec 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct the annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Haeryun Cho and discussed the purpose of the visit. The facility currently has six residents in care. The facility is a two story home with the upstairs being the licensee’s living quarters. There are four resident bedrooms, three bathrooms, a living room, kitchen, and attached two car garage on the first floor of the facility. The facility appears clean, safe and sanitary. LPA observed the resident bedrooms to have all the required components and furnishings. LPA observed the bathrooms to have toilet paper, paper towels and textured flooring in the shower. LPA observed the toxins and chemicals to be locked under the bathroom sink located in the hall behind the living room. LPA tested the water to be between 110.3-111 degrees Fahrenheit. LPA observed clean linens in a hall cupboard. LPA observed the kitchen to be clean and free of vermin. LPA observed the knives to be locked and stored in the kitchen cabinet by the stove and made inaccessible to residents in care. LPA observed the stove burners to not work without a lighter. LPA observed the centrally stored medication to be locked in a kitchen cabinet and made inaccessible to residents in care. LPA observed the emergency food to be located in the entry way of the facility. LPA observed the garage to be used as extra storage and is locked and made inaccessible to residents in care. LPA observed the backyard has a shaded seating area for resident use and is free of debris and obstructions. LPA and AD tested the carbon monoxide and smoke detectors and they were found to be operational. LPA reviewed staff files and 1 of 2 staff do not have a health screening on file. LPA observed 1 of 2 staff do not have updated annual training. LPA reviewed 3 resident files and 3 of 3 residents do not have an updated needs and services plan on file. Continue on LIC 809C LPA reviewed resident medications and 2 of 6 residents take vitamins with no physicians orders on file. Based on today’s inspection a technical violation and deficiencies are being issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report, LIC 809D, 858, 859, 811 and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Nov 4, 2025

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: POC

On 11/8/2024, LPA Mason arrived at the facility for the purpose of conducting a Plan of Corrections visit. LPA arrived at the facility and was greeted and granted entry by staff. LPA met with Administrator Haeryun Cho and explained the nature of the inspection. On 11/6/2024, the facility received a deficiency for knives not being locked. Based on observations today, LPA determined the facility had the knives locked in the garage. AD requested an extension to complete the training associated with the plan of correction. LPA stated the plan of correction will be due Monday 11/11/2024 by 5:00pm. LPA provided Administrator with guidance on creating a report in Microsoft Word Based on today's visit, no deficiencies are being issued. This report was reviewed with facility staff and provided.the state’s words, verbatim · CDSS document, Nov 8, 2024

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Nov 6, 2024