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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603649
Report Date: 04/07/2023
Date Signed: 04/07/2023 12:05:17 PM

Document Has Been Signed on 04/07/2023 12:05 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EVOLVE CARE, INCFACILITY NUMBER:
198603649
ADMINISTRATOR:DE VERA, MATTHEWFACILITY TYPE:
735
ADDRESS:1708 LINCOLN AVENUETELEPHONE:
(818) 749-2745
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 4CENSUS: 0DATE:
04/07/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Applicant- Matthew DeVera TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an announced pre-licensed visit and met with Applicant Matthew DeVera and Oliver Elma for the purpose of conducting a Pre-Licensing Inspection / Component III visit. The facility has an approved fire clearance to be licensed to serve four (4) ambulatory Adults clients Ages 18-59. Property has a back ADU, address 1706 Lincoln Ave approved and only to be used by staff, will remain locked and inaccessible to clients. The facility is a single story home: 4 bedrooms, 3 bathrooms, dining/ livng room , backyard and ADU home located in Pasadena,CA.

The physical plant was toured inside and out alongside with DeVera and Elma. Pre-Licensed Inspection Tool was used.

The following was observed/inspected
  • Each bedroom is designated as a private bedroom. Bedrooms are equipped with one bed, night-stand, chair, sufficient lighting, appropriate closet and drawer space.
  • All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Mattresses and bedsprings are in good repair.
  • Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture.
  • Sufficient supply of linens available to permit weekly changing and are stored in storage cabinet.
  • Sufficient personal hygiene supply available.
  • Laundry machine (wash/dryer) observed.
  • All (3) bathrooms have a working toilet, wash basin, and showers. All showers have a grab bars and non-skid mats.
  • There are enough bath towels, hand towels and wash cloths for all clients.


Continuation on 809-C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EVOLVE CARE, INC
FACILITY NUMBER: 198603649
VISIT DATE: 04/07/2023
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  • Smoke Detectors and Carbon monoxide detectors are interconnected approved in the Fire Clearance.
  • Two (2) Fire extinguishers observed and charged.
  • Cleaning solutions and sharps are locked in kitchen and only accessible to staff.
  • Kitchen cabinets, refrigerator/freezer, oven, microwave, dishwasher are in working condition, clean and sanitary.
  • Food Menu Samples observed.
  • Sufficient dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair
  • The facility has sufficient dining tables and chairs.
  • There is a designated space for Medications to be locked and inaccessible to clients, stored in the kitchen cabinets.
  • Client and Staff files will be stored and locked in designated file cabinet.
  • First Aid Kits observed with manual.
  • Physical plant is in good repair.
  • Building and grounds are free from hazards.
  • Window screens are in good condition.
  • Shaded area provided in the backyard to accommodate clients,no bodies of water observed.
  • Hot water temperature measured at 116.2 F , within Title 22 regulation.
  • The residence is equipped with central air and heating, temperature remained at a comfortable temperature.
  • Facility land line operable, facility number: 626-345-5040
  • Variety of activity supplies for clients observed.
  • Licensee reports no guns or weapons in the home.


Component III was also completed at the time of the visit and all required documents for Licensing were discussed. Facility met the physical plant requirements/ inspection as required per California Code of Regulations Title 22 Division 6.

LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.



Exit interview conducted and a copy of this report was provided to Applicant Matthew DeVera.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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