We R Evergreen

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Imaculada Vasquez arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by Administrator Ruby Joy Ferrer and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that four (4) residents live at this facility. The Administrator, Ruby Joy Ferrer gave a tour of the single story interior and exterior home. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Two (2) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. The Administrator’s certificate expiration date was 10/30/2027. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen. (Continued on next page) Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 74 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 114.0 degrees F. Laundry is done in the laundry room. There is a locked cabinet for storing laundry soap, cleaning supplies and chemicals in the closet in the garage. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is one (1) secured fireplace at this facility. There are zero (0) pools at the facility. There is one (1) secured gate that has a self-latching lock located on the northeast side of the house. LPA observed emergency supplies and two (2) first aid kit. The last emergency fire drill was conducted on 01/2026. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that staff had infection control training. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed that they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed seven (7) dual smoke detectors and a carbon monoxide detector throughout the facility. Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to Administrator, Ruby Joy Ferrer.the state’s words, verbatim · CDSS document, Apr 8, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that three (3) residents live at this facility. The Administrator, Ruby Joy Ferrer was advised of the annual however the Caregiver, Leticia Villaverde conducted and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Three (3) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. The Administrator’s certificate expiration date was 10/30/2025. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 108.0 degrees F. Laundry is done in the laundry room. There is a location for storing laundry soap, cleaning supplies and chemicals in the closet in the garage. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is one (1) secured fireplace at this facility. There are zero (0) pools at the facility. There is one (1) secured gate that has a self-latching lock located on the northeast side of the house. LPA observed emergency supplies and two (2) first aid kit. The last emergency fire drill was conducted on 02/01/2025. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that staff had infection control training. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed that they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed six (6) dual smoke detectors and carbon monoxide detectors throughout the facility. Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to Administrator, Ruby Joy Ferrer over the phone and Caregiver, Leticia Villaverde signed.the state’s words, verbatim · CDSS document, Mar 21, 2025

Type of visit: Required - 1 Year

On 4/19/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to conduct an annual required inspection. LPA was greeted and granted entry by Caregiver, Apollo Rodella who was informed of the purpose of the visit. Licensee, Ruby Ferrer was informed of LPA's visit. During today's visit, there was four (4) residents and one (1) staff present. The facility has a fire clearance for six (6) non-ambulatory residents ages 60 and above. The facility also has a hospice waiver for three (3) residents and LPA was informed three (3) residents are receiving hospice services at the facility. LPA toured the facility's interior and exterior with Caregiver Rodella. LPA observed the facility is made up of a one-story home with four (4) resident bedrooms, two (2) full bathrooms, three (3) living rooms, two (2) dining rooms, a kitchen, storage room, and attached garage. Indoor and outdoor passageways are free of obstruction. LPA observed the facility has more than a 2-day supply of perishable foods and 7-day supply of non-perishable foods. Caregiver Rodella tested one of the smoke alarms/carbon monoxide detectors and LPA found it to be operational. LPA observed charged fire extinguishers mounted throughout the facility. Medication is stored in a living room cabinet secured with a master lock. Disinfectants, cleaning solutions, and detergents are secured in the garage. The facility has additional linen, blankets, towels, comforters and incontinent supplies available for residents in care. LPA reviewed random resident files. Resident files reviewed have signed and updated physician reports and admission agreements. Residents rights, complaint procedures, Long Term Care Ombudsman information, and facility sketches are posted near the facility's front entrance. The facility does not safeguard the residents' cash resources. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Caregiver Rodella.the state’s words, verbatim · CDSS document, Apr 19, 2024