Evergreen Court

The inspection identified multiple fire and life safety code violations including improper electrical equipment use, missing maintenance documentation for critical fire protection systems (sprinklers, smoke detectors, fire extinguishers), obstructed fire safety equipment, missing exit signage, and incomplete fire drill documentation for third quarter 2025. The facility corrected most violations on-site during the inspection (items 2-4, 9-12, 14), demonstrating responsiveness, but failed to provide required documentation for monthly smoke detector testing and quarterly fire drills, indicating gaps in record-keeping systems. While no immediate life-safety threats were present, the pattern of maintenance documentation failures across multiple fire protection systems represents a moderate systemic compliance issue that the facility partially addressed through immediate correction of physical deficiencies.

This follow-up inspection identified five uncorrected deficiencies previously cited in February 2025, demonstrating a pattern of systemic non-compliance. Violations include incomplete resident assessments risking unidentified care needs, unsigned service agreements, unauthorized occupancy of three unapproved rooms, non-functional ventilation systems affecting all 37 residents, and inadequate service planning documentation. The facility's response was inadequate, as evidenced by the repeat citations and imposition of $1,500 in civil fines for failing to correct previously identified deficiencies within the allotted timeframe, indicating minimal corrective action was taken despite prior notification.

This fire safety inspection identified multiple moderate violations including combustible materials in egress areas and electrical rooms, non-functioning emergency lighting and exit signs, two fire doors failing to latch properly, and extensive missing documentation for required safety system inspections (fire drills, sprinkler testing, fire alarm maintenance, emergency lighting tests, hood cleaning, and fire door inspections). The facility status was marked as 'disapproved' at time of inspection, and no evidence of corrective actions, investigation, or facility response is documented in this report. The violations represent systemic failures in both physical safety compliance and required inspection/maintenance programs, though none constitute immediate life-threatening conditions.

This residential care facility exhibited a systematic pattern of fire safety non-compliance across multiple critical systems including missing fire drill documentation for all shifts across all quarters, no maintenance records for sprinkler systems, fire alarms, emergency lighting, and fire doors, plus immediate hazards such as combustible materials blocking exits and in electrical rooms, non-functioning emergency lighting and exit signs, and doors that fail to latch properly. The facility's response was grossly inadequate, failing to provide any of the required inspection and testing documentation requested and showing no evidence of having implemented legally mandated fire safety protocols, resulting in inspection disapproval. The combination of systemic failures in fire protection systems, blocked egress routes, and complete absence of required safety documentation creates severe life-safety risks for vulnerable residents.

The May 2023 inspection identified 13 violations including missing fire safety documentation (fire door inspections, fire/smoke damper testing, sprinkler service records, emergency lighting tests), improper electrical usage (daisy-chained power strips, extension cords, missing junction box covers), equipment maintenance issues (kitchen hood cleaning, fire extinguishers on floor), and non-functioning exit signs. The facility responded promptly and effectively, correcting all violations within six weeks as confirmed by the July 2023 follow-up inspection showing full approval status. The violations represented systematic documentation gaps and maintenance oversights rather than immediate life-safety threats, and the facility's timely comprehensive remediation demonstrates appropriate commitment to regulatory compliance and resident safety. No evidence of resident harm or imminent danger was present during either inspection visit.