Evergreen Home Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Licensee (LNS) Thu Nguyen. upon arrival, LNS took LPA body temperature, and checked LPA in the visitor log book. LPA toured the facility inside out with LNS. COVID posters were observed at main entrance and in the facility. Screening station at the main entrance with masks, hand sanitizer, thermometer and visitor log book was observed. Living room, kitchen, dinning room, family room and two restrooms were inspected. Some trash cans were observed without covers. LNS stated facility will replace the trash cans with covers in 3 days. Paper towel were observed with holders. Cloth towels were observed at kitchen and restrooms. Three single resident bedrooms and 1 shared resident room were inspected. One staff live-in room is in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 108 degree F in facility. Five residents and one staff were observed in facility. Fire extinguisher was serviced on 6/03/2021. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. LNS tested the smoke detectors, and they were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. LNS stated all the residents and staff are fully vaccinated and done with booster. No citation were noted today. Exit interview was conducted with LNS. This report was provided to LNS for signature.the state’s words, verbatim · CDSS document, May 20, 2022

Allegation investigated: The facility does not have canned foods.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint visit to deliver investigation finding. LPA met with Licensee (LNS) Thu Nguyen. On 05/06/2021, the Department received a complaint of the above allegation. On 05/12/2021, an unannounced complaint inspection visit was conducted. During the investigation, LPA interviewed two staff and four residents and toured the facility. Residents roster, 4 weeks of facility food menu, staff duty schedule, and monthly grocery shopping list proposed by ADM were obtained. Continued, see LIC 9099-C, pages 1 of 3 Unsubstantiated The facility does not have canned foods: On 05/12/2021, LPA visited facility and inspected the foods in the refrigerator and foods in the pantry. LPA observed the foods in the refrigerator around half of capacity of the refrigerator, and the foods in the pantry around 1/3 of the capacity of the pantry with 15 cans of food. On 05/12/2021, two staff were interviewed. 2 out of 2 stated the supply of perishable food is less than 2 days and the nonperishable food supplies is less than 4 days. However, 1 out of 2 staff interviewed stated she never had the situation where there was no food to cook. LPA interviewed four residents (R1 - R4). Two residents stated that they always have enough foods for 3 meals and two snacks. The other two residents stated they do not have any complaint. On 06/23/2021, LPA visited the facility and inspected the foods in the refrigerator and the foods in the pantry in the facility. LPA observed the foods in refrigerator and foods in pantry were more than 2/3 of the capacity. The 2 day perishable food supplies and 7 day nonperishable food supplies were observed sufficient. Two additional staff were interviewed and stated the condition of food supply in stock was getting better than one month ago. On 07/19/2021, LPA inspected the foods in the refrigerator and foods in the pantry with administrator (ADM). LPA observed the foods in refrigerator were full, and the foods in the pantry were almost full. Licensee (LNS) stated LNS goes grocery shopping at least two times per week. The 2 day perishable food supplies and 7 day nonperishable food supplies were observed sufficient. Continued, see LIC 9099-C, pages 2 of 3 On 5/12/2021, 6/23/2021, and 7/19/2021 during the investigation visit, facility was observed to have sufficient canned food. There are no picture that staff or residents can provide to show that the facility did not have canned food. No residents complained the food supplies were not enough. The department has investigated the above allegation. Based on the investigation, observations, records reviewed, and interviews conducted, the Department found that the above allegations is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with Licensee. This report was provided for signature.the state’s words, verbatim · CDSS document, Apr 18, 2022 · control 26-AS-20210506153222

Allegation investigated: Staff not providing adequate service to resident. Staff failed to treat resident with dignity and respect

Licensing Program Analyst (LPA) Steve Nguyen conducted an unannounced visit to deliver the complaint investigation finding. LPA met with Licensee Thu Nguyen. On 9/15/2021, Licensing Program Analyst (LPA) Steve Nguyen interviewed reporting party (RP). RP stated that RP does not have any firsthand knowledge of allegations and does not have anything further to add. Unsubstantiated On 9/15/2021, LPA conducted an inspection of facility with AD: Observed medication was locked, cleaning supplies locked, sharps are locked, all residents in common areas were well kept, all staff wearing masks and the practice of social distancing in effect. LPA requested the following documents but not limited to: resident and staff rosters, physician’s orders, progress notes, admission agreement, services and needs, and or available IPP, and LIC 634 Incident Reports for the year 2021. From 9/15/2021 through 9/16/2021, LPA interviewed 5 Staff. 5 out of 5 staff denied any issues of neglect, and/or inadequate service pertaining to the Activities of Daily Living for residents. 4 out of 5 staff denied any incident concerning lack of respect for the residents from staff. 5 out of 5 staff stated that community outings do occur at facility. On 9/15/2021, LPA attempted to interviewed 3 residents. 2 residents were non-verbal and/ or unwilling to be interviewed. 1 resident denied both allegations. LPA reviewed the following but not limited to documents: resident and staff rosters, physician’s orders, progress notes, admission agreement, services and needs, and or available IPP, and LIC 634 Incident Reports for the year 2021. No instances of inadequate service or lack of respect for residents were found. The Department has investigated the above allegations. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above 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. No Deficiencies cited under California Code of Regulations Title 22 Exit interview conducted with Licensee Thu Nguyen and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 22, 2021 · control 26-AS-20210913143102

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Steve Nguyen conducted an inspection of facility with Administrator Sashi Kumar. LPA observed the windows and wall from one of the bedroom to be broken. LPA advised Licensee and Administrator that the window and wall needs to be fixed. Licensee acknowledged and confirmed understanding. Licensee gave the fix date as 9/20/2021 and will provide Department with pictures and/ or pictures with receipts upon completion.the state’s words, verbatim · CDSS document, Sep 15, 2021

Allegation investigated: Facility had insufficient food supply

Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced initial investigation visit. LPA met with the House Manager Ian Sumbi. LPA interviewed 2 residents. 2 out of 2 residents stated they were provided enough food in the facility. LPA interviewed 3 staff. 3 out of 3 staff stated there was sufficient food in the facility for residents. LPA toured the facility. LPA inspected the refrigerator and the pantry storage. LPA estimated there were at least 2 days of perishable and more than 7 days of nonperishable foods in the refrigerator and the pantry respectively. Unsubstantiated This Department has investigated the above allegation. Based on interviews and observations, the Department found that the above allegation is UNSUBSTANTIATED. Unsubstantiated finding indicated that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. This report was reviewed with House Manager and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 3, 2021 · control 26-AS-20210728081426