<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200705
Report Date: 12/03/2024
Date Signed: 12/03/2024 11:36:02 AM

Document Has Been Signed on 12/03/2024 11:36 AM - 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:EVERGREEN HAVENFACILITY NUMBER:
198200705
ADMINISTRATOR/
DIRECTOR:
ARLENE FELICIANOFACILITY TYPE:
740
ADDRESS:2513 WEST 168TH STREETTELEPHONE:
(310) 630-0817
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Administrator Arlene FelicianoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/03/24, Licensing Program Analyst (LPA), Lizeth Villegas, conducted an unannounced annual visit to the facility listed above. LPA met with Administrator Arlene Feliciano, as 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. Administrator provided with upcoming fees info and pin. Facility has an active liability insurance with expiration date of 12/29/24.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) resident's rooms, (2) common bathrooms, (1) private bathrooms, living area, dining area, kitchen, laundry area, a detached garage, and a large outside backyard with covered patio area. LPA inspected all bedrooms; all rooms were observed clean and in good repair. All rooms had the required furniture including a bed, dresser, night stand, 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. 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 105F-120F. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods. LPA observed all sharps and cleaning supplies secured in a cabinet under the kitchen sink and are inaccessible to residents. Land line, smoke detectors, carbon monoxide detector, and fire extinguishers observed to be operational.

LPA conducted a review of (3) staff files, 3 resident files, and 3 medication administration files, no discrepancies were observed. LPA observe medications stored and secured in a locked cabinet. No firearms or bodies of water observed.

Exit interview conducted, appeal rights explained, and a copy of this report was provided.

Janae HammondTELEPHONE: (424) 544-1027
Lizeth VillegasTELEPHONE: (818) 391-9974
DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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 12/03/2024 11:36 AM - 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: EVERGREEN HAVEN

FACILITY NUMBER: 198200705

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/03/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87303 Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors.


=
Deficient Practice Statement
1
2
3
4
Based on [(observation) and (interview), the licensee did not comply with the section cited above as the one of the garage windows is broke and has a missing glass which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
1
2
3
4
Licensee will have window fixed/replaced and will submitt proof of repair to LPA by POC due date.
Lizeth.villegas@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae HammondTELEPHONE: (424) 544-1027
Lizeth VillegasTELEPHONE: (818) 391-9974

DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024

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