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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197608601
Report Date:
08/19/2021
Date Signed:
08/20/2021 07:32:43 AM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
EVERGREEN ELDERLY CARE LIVING
FACILITY NUMBER:
197608601
ADMINISTRATOR:
ZOREEN RAI
FACILITY TYPE:
740
ADDRESS:
45237 SANCROFT AVENUE
TELEPHONE:
(661) 942-3495
CITY:
LANCASTER
STATE:
CA
ZIP CODE:
93535
CAPACITY:
6
CENSUS:
2
DATE:
08/19/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:58 PM
MET WITH:
Zoreen Rai
TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Angelica Arambulo conducted a case management visit on the status of the facility. The LPA was informed that at tihis time they have 2 residents. Which will allow them to continue with the financial suupport they need to stay open. Facility is not closing and if they do the administrator was given instructions on procedures.
The facility was observed to be clean and safe. The residents observed to have a private room.
Exit interview conducted. Report to be mailed since no email on file for administrator Zoreen RAi.
SUPERVISOR'S NAME:
Eva Miller
TELEPHONE:
(818) 596-4373
LICENSING EVALUATOR NAME:
Angelica Arambulo
TELEPHONE:
(818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE:
08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
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