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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608072
Report Date: 08/30/2024
Date Signed: 08/30/2024 02:16:34 PM


Document Has Been Signed on 08/30/2024 02:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:EVERGREEN SENIOR CAREFACILITY NUMBER:
197608072
ADMINISTRATOR:EVANGELINA REYESFACILITY TYPE:
740
ADDRESS:528 HOWARD STREETTELEPHONE:
(626) 284-0503
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY:14CENSUS: 14DATE:
08/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Evangelina Reyes, Administrator TIME COMPLETED:
02:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to issue citation for forfeiture of License. LPA met with Administrator Evangelina Reyes and discussed purpose of visit.

The investigation revealed that current Licensee Jason Liang had sold the facility in 2021. Mr. Laing stated to the Department, that he is not involved in the day-to-day operations of the facility, and those duties are now be handled by current Unlicensed Operator Hyo Sook Kim.

Due to the admission statement from Mr. Liang, his License was relinquished.

Deficiency cited, please see 809D for details.

Exit interview conducted, report and appeal rights provided.



SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/30/2024 02:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: EVERGREEN SENIOR CARE
FACILITY NUMBER: 197608072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2024
Section Cited
CCR
87112(a)(a)

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87112(a)(a) Conditions for forfeiture of a residential care facility for the elderly license shall be as specified in Health and Safety Code section 1569.19.

(a) The licensee sells or otherwise transfers the facility or facility property, except when change of ownership applies to transferring of stock when the facility is owned by a corporation, and when the transfer of stock does not constitute a majority change in ownership. The sale of a facility shall be subject to the requirements of this chapter.

This deficiency is evidenced by:
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LPA took possession of current Llicense during facility visit. .
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Licensee has relinquished ownership of Facility License. Licensee stated property has been sold and Licensee will surrender Facility License on 08/30/2024.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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