198200705-11-29-2022-11-AS-JRAE-CLMRG5-20221129120009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198200705
Report Date: 11/29/2022
Date Signed: 11/29/2022 12:00:24 PM

Document Has Been Signed on 11/29/2022 12:00 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	EVERGREEN HAVEN		FACILITY NUMBER:	198200705
ADMINISTRATOR:	ARLENE FELICIANO		FACILITY TYPE:	740
ADDRESS:	2513 WEST 168TH STREET		TELEPHONE:	(310) 630-0817
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS:	DATE:	11/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Velma Cabading Caregiver and later Arlene Feliciano Administrator		TIME COMPLETED:	12:15 PM

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Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Velma Cabading Caregiver and later Arlene Feliciano Administrator and the purpose of today’s visit was explained.

There are currently (6) residents in the facility. (6) residents are ambulatory, (0) are non-ambulatory, (0) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (7) bedrooms, one of which is for staff (2) full bathrooms, shaded back yard, front yard, laundry room and attached 2 garage.

LPA and Feliciano toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1- 6 are occupied by residents , bedroom 7 if for staff, all contain the mandated furniture. The (2) bathrooms have grab bars and non-skid mats and are clean and operational. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is within title limits, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (2) fire extinguishers is fully charged.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN HAVEN	FACILITY NUMBER: 198200705
	VISIT DATE: 11/29/2022

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Cont

Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards.

The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked, sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing not completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & IPAD for residents to use, resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days. All residents and staff are vaccinated and boosted. Technical Advisory (TA) issued for Staff Fit Testing

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time

An exit interview was conducted with Arlene Administrator, and a hard copy was provided

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC809 (FAS) - (06/04)

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