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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608601
Report Date: 04/01/2022
Date Signed: 04/01/2022 01:39:27 PM


Document Has Been Signed on 04/01/2022 01:39 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:EVERGREEN ELDERLY CARE LIVINGFACILITY NUMBER:
197608601
ADMINISTRATOR:ZOREEN RAIFACILITY TYPE:
740
ADDRESS:45237 SANCROFT AVENUETELEPHONE:
(661) 942-3495
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:6CENSUS: 0DATE:
04/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Zoreen Rai, LicenseeTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Shira Stamps responded to the facility to follow up on a facility closure. On March 18, 2022 the Department received an email indicating the facility has ceased operation.

Entrance interview conducted.

LPA arrived at the facility at 1:00pm. There was no answer, and LPA called the Licensee. The Licensee arrived at the facility at 1:16pm, and LPA conducted a tour of the facility to make sure the licensee has ceased operation. There is no evidence of residents living in the home. The Licensee has begun to remove furniture. The Licensee has provided LPA with the closure letter. LPA has verified that the licensee has ceased operation. The Licensee has mailed in the original license to Community Care Licensing.

LPA reminds the Licensee that should they decide to operate a community care facility in the future that a new application, plan of operation, and fee shall be submitted. The licensee shall not operate until approval of a new license.

Exit interview conducted and copy of report delivered, and closure survey will be emailed.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira StampsTELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022
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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