Inspection visit

ComplaintOctober 28, 2025

EVERGREEN COURTLicense 1072093714 citations on this visit

4 citations recorded

Inspector’s narrative

What the inspector wrote

CONT... During visits conducted on 5/31/25 and 10/28/25 LPA observed chemicals, sharps and medications unlocked and accessible to residents in care posing a danger. This allegation staff do not ensure toxins are inaccessible to residents is SUBSTANTIATED. Deficiency cited on attached 9099D. Interviews were conducted with staffs and residents. LPA was informed staff argues with their significant other and afterward would get upset with residents and yell at them. Residents are handled in a rough manner by staff after staff’s arguments with their significant other. During complaint visit on 05/13/25, LPA observed staff attempting to lift a resident in living room from the resident’s chair. LPA observed the staff having difficulty lifting the resident. The allegations staff yells at residents and staff handles residents in a rough manner are SUBSTANTIATED. Deficiency cited on attached 9099D. During complaint visit on 5/31/25, LPA observed S1 providing care to the residents. Records were reviewed, facility staff roster showed S1 was fingerprint cleared but not associated to the facility. This allegation Licensee does not ensure that staff have fingerprint clearance is SUBSTANTIATED. Deficiency was cited on a case management visit conducted on 5/31/25. During complaint visit conducted on 5/31/25, LPA completed a tour of the facility. LPA observed Lantus Solostar 100unit.ml medications for R4 unlocked in a medication lock box inside the bottom shelf of the refrigerator. During an interview conducted with Administrator, Administrator informed LPA, R4 was no longer taking the medication per physicians’ orders. R4’s file was reviewed, no order for Lantus medication was discontinued. During medication audit, discontinued medications for 2 of the 6 residents were not properly destroyed and recorded. This allegation staff are mismanaging residents medications is SUBSTATIATED. Deficiency issued on attached 9099D. During complaint investigation, interviews were conducted, and records were reviewed. Interviews conducted with staff and residents confirmed residents were being showered two times a week. Licensee and Administrator confirm 2 out of 6 residents requesting or needing to be showered more than 2 times a week and are not being showered as request/needed due to "limited staffing to accommodate the residents’ request". Residents receiving hospice care are being showered by their hospice care agency weekly. Facility shower log records show all residents are showered two times weekly. Staff records in the facility computer system show when staff are giving showers. Based on interviews conducted and records reviewed, the allegation staff do not ensure residents’ bathing needs are met is SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. During visit conducted on 5/31/25, LPA observed surveillance cameras in the hallway facing directly into bedroom #1 and bedroom #4. The allegation staff do not ensure residents have privacy in their bedroom(s) is SUBSTANTIATED. Deficiency cited on attached 9099D. The preponderance of evidence standard has been met per Title 22. Deficiencies cited per California Code of Regulations, Title 22. If not corrected, deficiencies will have a direct impact to residents in care.Exit interview completed with Licensee/Administrator, Minakshi. Plans of correction was developed by Licensee and reviewed by LPA. A copy of this report, deficiencies and appeal rights were provided.

Citations

13 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87211(a)(1)Type B
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.
87303(a)Type B
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.
87309(a)Type A
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.
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87465(c)(1)Type A
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.
87465(c)(2)Type A
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.
87465(h)(2)Type A
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.
87468.1(a)(13)Type B
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
87506(b)(17)Type B
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.
87609(b)(4)Type B
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.
87615(a)(1)(a)Type A
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.
87411(a)Type B
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.
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87468.1(a)(1)Type B
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.
87468.2(a)(8)Type B
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.
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FAQ · About this visit

Common questions about this visit

What happened during the October 28, 2025 inspection of EVERGREEN COURT?

This was a complaint inspection of EVERGREEN COURT on October 28, 2025. 4 citations were issued: 4 Type B.

Were any citations issued to EVERGREEN COURT on October 28, 2025?

Yes, 4 citations were issued (0 Type A, 4 Type B). The first citation was for: "Based on record review and interview conducted, LPAs reviewed the residents’ files and observed hospital discharge recor..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated June 22, 2026. If you believe any information is inaccurate, report it here.

Complaint·October 28, 2025