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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003773
Report Date: 11/07/2022
Date Signed: 11/07/2022 11:13:10 AM


Document Has Been Signed on 11/07/2022 11:13 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:EVERGREEN CARE HOMEFACILITY NUMBER:
306003773
ADMINISTRATOR:HAERYUN CHOFACILITY TYPE:
740
ADDRESS:4715 ST. ANDREWS AVENUETELEPHONE:
(562) 480-9453
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY:6CENSUS: 6DATE:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Haeryun ChoTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Administrator Haeryun Cho and explained the reason for the visit. Administrator Haeryun Cho has an administrator certificate expiring on 06/14/2023.

At 10:02 AM, LPA toured the facility with Administrator Cho. Facility is two stories with licensee living quarters on the second floor. Facility has six residents in care during today's visit, with no residents on hospice care. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident's rooms had required elements as well as restrooms stocked with soap/ sanitizer. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident and staff temperatures daily but does not document. Facility has covid precaution postings as well as required department postings. LPA toured the kitchen and observed ample food supply. Kitchen appliances are operational. LPA observed medications and toxins are secured during today's visit. Facility has completed the mitigation plan and plan has been approved. LPA observed emergency food and water as well as the first aid kit which contained all required items. Fire extinguisher is mounted and charged. Smoke detectors tested operational. LPA toured the outside grounds and observed the outside visitation area. Exit gate is unlocked and self latching. Residents participate in activities such as exercise and bible study. Facility has ample supply of PPE and cleaning supplies. All staff and residents are vaccinated for Covid-19. LPA reviewed select resident files and all files were up to date including updated emergency information and physician reports.

LPA consulted with Administrator regarding the importance of hand washing signs in facility restrooms as well as reviewing all physician reports for accuracy.
No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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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