Evergreen Court

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above when LPAs toured the facility at approximately 09:34AM, Clorox disinfecting wipes under the hall bathroom sink unlocked, at 09:35AM, peri care wash bottles unlocked in bedroom #3, at 09:39AM multiple chemicals stored unlock under the kitchen sink, at 09:40AM, sharps in kitchen cabinet next to the stove not properly closed, 09:43AM eye wash solution packets and alcohol pads observed unlock in first aid kit in hallway and a box filled Ensure Max protein nutritional supplement unlock in pantry, at 09:48AM paints in a clear plastic bin on resident desk unlock, and approximately 11:09AM craft paints and a box of acrylic paints under and on top of desk in the livingroom all were accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Require physician-written PRN medication directions

Based on record review and interviews conducted, the licensee did not comply with the section cited above when LPAs reviewed R2’s file and observed a handwritten note on a white blank printer paper without a physician’s signature for medication (Alprazolam 0.23 mg) and for crush medications, which poses a potential health or personal rights risk to persons in care.

Give PRN medication by physician order

Based on observation and records reviewed, LPAs checked R1’s medications, R1’s MAR, and centrally stored medication list. R1’s Tamsulosin Hcl 0.4mg bubble pack filed on 09/29/25 was opened and administered 10/1/25. R1’s MAR record medication Tamsulosin administered daily at 08:00AM from 10/10/25 to 10/28/25. Medication was observed 1 medication Tamsulosin capsule left, which poses/posed an immediate health and safety risk for the person in care.

Facility personnel sufficiency and competence

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidence by: review of records and LPA observations. The licensee did not comply with the section cited above in that LPA observed 2 unused Lantus Solostar 100unit.ml insulin pens for R4 in refrigerator filled on 3/11/5. Interviews with Licensee, Administrator, staff and R4 disclosed R4 does not get injections as prescribed. No discharge of medication was observed in R4’s file. Interviews with Licensee, Administrator, staff and residents disclosed residents are only being showered 2x weekly and not as needed or requested. This poses a potential health safety and or personal rights risk to residents in care.

Based on record review, the licensee did not comply with the section cited above when LPAs reviewed R6’s file and observed notes in hospice plan of care dated 10/14/25 record R6 has Stage 3 wound to right buttock, which poses a potential health or personal rights risk to persons in care.

Agree in writing on agency and facility responsibilities

Based on record review, the licensee did not comply with the section cited above when LPAS reviewed R1’s file, who’s currently receiving home health with no current home health care plan on file, which poses a potential health or personal rights risk to persons in care.

Based on record review, all residents’ files were reviewed. An appraisal (Lic 603) and needs and services plan (Lic 625) was not observed in R2’s file, R3’s Lic 625 was not observed in R3’s file, Medical Consent form (Lic 627C) was not observed in R1 and R4’s files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Right to freedom from abuse and neglect

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidence by: interviews conducted and LPA observations. The licensee did not comply with the section cited above in that interviews confirmed staff would be upset and yell at the residents. LPA observation of resident being transferred by staff with difficulty and a rough manner. The poses a potential health safety and or personal rights risk to residents in care.

Based on interviews conducted and observation, the licensee did not comply with the section cited above when LPAs toured the facility at approximately 09:47AM, R6’s belongings was observed in bedroom 1 walk-in closet locked and only accessible to staff, which poses a potential health or personal rights risk to persons in care

Dignity in personal relationships

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: LPA observation. The licensee did not comply with the section cited above in that surveillance cameras in the hallway facing directly into bedroom #1 and bedroom #4. This poses a potential health safety and or personal rights risk to residents in care.

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above when LPAs observed at approximately 09:40AM, medications stored in kitchen cabinet unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to person in care.

Report specified resident events within seven days

Based on record review and interview conducted, LPAs reviewed the residents’ files and observed hospital discharge record for R5 recording R5 had gone to the hospital on 08/09/25 and R3 went to the hospital on 01/16/25. The department did not receive a written report when R3 and R5 went to the hospital, this poses a potential health and safety risk to residents in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, LPAs toured the facility and observed at approximately 09:50AM the air filter was observed full of thick dust in hallway near laundry room, at approximately 09:53AM multiples sacks filled with spiders eggs observed behind laundry room door, and at approximately 10:00AM the right side backyard fence board was broken and spider webs were observed, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Request transfer of criminal record clearance

87411 Personnel Requirements - General(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement was not met as eivdence by: LPA observation of the Guardian Roster at 9:15 am on 5/31/25. Staff 1 was not associated to the facility. If not corrected this poses an immediate risk to the health safety and or personal rights of residents in care.***An immediate civil penalty in the amount of $500 was assessed.***

Facility must keep complete hospice care plan on file

87633 Hospice Care of Terminally Ill Residents (b) A current and complete hospice care plan shall ...(4) A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility. This requirement was not met as evidence by: LPA observation of R1's hospice care plan provided by Administator, Steve dated 09/05/2024-12/03/2024. This poses an immediate health safety and or personal rights risk to residents in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by: LPA observation of R1s hospice plan indicating R1 was being treated for a head wound. Review of facility incident reportings does not show facility reported to CCL. If not corrected this poses an immediate health safety and or personal rights risk to residents in care.

Maintain fire clearance before retaining specified persons

87202 Fire Clearance(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidence by: LPA observation of 3 exit doors (exit #1, exit #8 and #7) to have a door lock at the top preventing residents from exiting. If not corrected this poses an immediate health safety and or personal rights risk to residents in care.***An immediate civil penalty in the amount of $500 is hereby assessed for fire clearance***

Maintain separate complete record for each resident

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement was not met as evidence by: LPA observation of resident files. During the annual records were observed incomplete. Physicians report was incomplete/inaccurate. Pre-admission/reappraisals missing. Physicians’ orders missing for hospital beds/bed railing.

Food handling safeguards during storage and service

87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidence by: LPA observation of food in refrigerator was not properly stored/dated. This poses a potential health, safety and or personal rights risk to residents in care.

Ensure hazardous items are locked and not unattended

87309 Storage Space and Access(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidence by: LPA observation of chemicals/items posing a danger on bathroom #3 countertop, in storage area in back yard and in storage shed all unlocked and accessible to residents in care. This poses a potential health, safety and or personal rights risk to residents in care.

Hazardous areas restricted from residents

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement was not met as evidence by: LPA observation of open patio on back of facility without hand railings or lighting. This poses a potential health, safety and or personal rights risk to residents in care.

Clean linen quantity and hygiene supplies

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement was not met as evidence by: LPA observation of linen. The facility has 7 towels for 5 residents in care. This poses a potential health, safety and or personal rights risk to residents in care.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: LPA observation of: attic space door observed dirty and in need of painting. Vent in hallway near office observed hanging and in need of cleaning. AC/heating vents in facility observed dirty and in need of cleaning. Doorway from living room to sitting area observed in need of touch up paint. Gates on right and left side of facility not self-latching. This poses a potential health safety and or personal rights risk to residents in care.

Maintain physician order documentation in resident record

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement was not met as evidence by: LPA observation of residents beds with hand railing. A written order for this postural support was not observed in resident files reviewed. This poses a potential health, safety and or personal rights risk to residents in care.

Food storage temperature control requirements

87555 General Food Service Requirements (b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement was not met as evidence by: LPA observation of freezer being packed and not having adequate air circulation to maintain temperature. This poses a potential health, safety and or personal rights risk to residents in care.

87307 Personal Accommodations and Services (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement was not met as evidence by: LPA observation of storage area accessible through R6’s bedroom. This poses a potential health, safety and or personal rights risk to residents in care.

Maintain facility in clean, safe, sanitary condition

LPA observations of vents in hallways in need of dusting/air filters, restroom #2 tub in need of cleaning, food in freezer not dated/stored properly, walls and doors in need of wiping down, storage area accessible through resident #6 bedroom. This poses a potential health safety and or personal rights risk to residents in care.