198200705-12-6-2023-11-AS-WGIS-CY9SWR-20231206131447

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198200705
Report Date: 12/06/2023
Date Signed: 12/06/2023 01:14:58 PM

Document Has Been Signed on 12/06/2023 01:14 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 ASC, 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: 6	DATE:	12/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:			TIME COMPLETED:	01:30 PM

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On 12/06/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Administrator, Arlene Feliciano, and the purpose of today's visit was explained. The facility is licensed for six (6) ambulatory and non-ambulatory residents ages 60 and over with a Hospice Waiver for one (1) resident.
Structure/Physical Plant The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident's rooms, staff area near the dining area, three (3) bathrooms, living area, dining area, kitchen and outside covered patio area. LPA observed all walkways outside of the home to be clean, clear, and free of debris and hazards. LPA did not observe any bodies of water on the premises.
Bedrooms LPA inspected all bedrooms; all rooms were observed clean and in good repair. All rooms had the required furniture including a bed, dresser, nightstand, chair, and ample storage space for resident’s personal belongings. All beds were observed to have the required linens including a mattress pad, fitted sheets, blanket, comforter, and pillow. All linens were observed in good repair. LPA observed an adequate supply of linens. All rooms were observed to have ample lighting.
Bathrooms LPA inspected all bathrooms and were found to be within Title 22 regulations. All bathrooms were observed clean, operable, and in good repair. All bathrooms had secured safety handrails and a nonskid mat. The showers were free of mildew and/or mold. LPA observed an ample supply of personal hygiene products and towels in good repair. The water temperature in the bathrooms measured 113.3-degrees, 114.2-degrees, and 111.6-degrees Fahrenheit.

Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed an ample supply of cookware, dining ware, and cutleries in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods. All appliances were observed operable. The water temperature measured 113.7-degrees Fahrenheit. LPA observed all sharps secured in a locked drawer in the kitchen and are inaccessible to residents. LPA observed cleaning supplies secured in a cabinet under the kitchen sink and are inaccessible to residents.

Continued on LIC809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN HAVEN	FACILITY NUMBER: 198200705
	VISIT DATE: 12/06/2023

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Common Rooms LPA inspected all common rooms. The living room has a large couch to accommodate all residents. The family room has multiple chairs and a couch to accommodate residents. LPA observed a fireplace screened and not accessible to residents. The dining room has a large rectangular table with six chairs to accommodate all residents. LPA observed games, puzzles, magazines, and books stored in the dining room for residents. The facility was maintained at a comfortable temperature. LPA observed all walkways to be clean, clear, and free of hazards.
Medications LPA observed centrally stored medications secured in a locked cabinet in the kitchen and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medications and Medication Administration Records (MARs) for three (3) residents. The resident’s MARs and medication are consistent with properly documented records.
Files/Interview LPA reviewed three (3) Resident files and observed the files contained the required documents. LPA interviewed all Resident’s, and they are happy with the care and services they receive from staff. LPA reviewed the Administrator’s and two (2) staff files and observed they contained the required documents, certification, and training. LPA interviewed the staff, and all were able to answer questions regarding resident care, procedures, policies, and resident personal rights. LPA reviewed the staff training logs and observed staff have the required training hours.
Safety LPA observed all required signs and documents posted throughout the facility. LPA reviewed and received a copy of the facilities Liability Report which expires on 12/28/23. Smoke detectors and Carbon Monoxide detectors are operable. LPA observed two (2) fully charged fire extinguishers, purchased on 01/27/23. The last facility inspection from the Torrance Fire Department was on 01/27/23. LPA inspected the First Aid Kit and found it contained the required items. The last emergency drill was conducted on 09/20/23. The facility has a working landline telephone. There are no firearms or ammunition stored at the facility.
Infection Control Upon entry LPA observed a sign-in for visitor and a hand sanitizing station at the front door. LPA observed mandated infection control signs posted throughout the facility. LPA observed staff sanitizing high frequency touch areas after breakfast. LPA observed a 30-day supply of Personal Protective Equipment (PPE).

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Arlene Feliciano, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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