306005210-5-22-2026-22-AS-JCHO-DUBQVN-20260522123038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005210
Report Date: 05/22/2026
Date Signed: 05/22/2026 12:31:02 PM

Document Has Been Signed on 05/22/2026 12:31 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	EVER CARE		FACILITY NUMBER:	306005210
ADMINISTRATOR/ DIRECTOR:	MOKHTAZAD, SHAHIN		FACILITY TYPE:	740
ADDRESS:	24611 SPARTAN STREET		TELEPHONE:	(949) 616-4785
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6		CENSUS: 6	DATE:	05/22/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Shahin Mokhtarzad- Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:45 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	Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA was greeted and granted entry by Caregiver Maricris Ampuan after introducing self and stating the reason for the visit. Administrator (Admin) Shahin Mokhtarzad shortly arrived on site to assist with the inspection. Admin Mokhtarzad has a valid certificate expiring November 11, 2027. The following was observed during the inspection accompanied by Admin: This is a single story property located in a residential neighborhood comprised of six private resident bedrooms and six private resident half bathrooms. There is a walk-in community shower shared by all residents. There is an additional private bedroom and full bathroom for the two live-in caregivers. Facility is operating within the conditions and limitations specified on the license. LPA observed six residents in care with one under hospice and another resident who is bedridden. LPA observed two staff present on duty. LPA toured the physical plant and observed the kitchen appliances and all bathrooms require a deep cleaning The kitchen exterior/interior refrigerator and freezer shelves and doors had food stains and particles. All other common areas were inspected including the attached two car garage. LPA inspected all resident bedrooms. The resident bedrooms' were appropriately furnished, beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space for each residents' personal belongings were observed. All bathrooms were found be operational but require a deep cleaning. The toilet bowls had fecal matter and urine causing odor, and the bathroom floor and shower had evidence of pink slime or film. Slip resistant mats were observed to be available.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EVER CARE	FACILITY NUMBER: 306005210
	VISIT DATE: 05/22/2026

NARRATIVE

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The hot water temperature in the resident bathrooms measured within range at 112.8, 112.6, 111.3, 111.3, 118,9, and 111.2 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed ample two-day supply of perishables and seven-day supply of non-perishable food.

LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. The exit gates are operational, and there are sufficient seating and shading in the patio area. There are no bodies of water on premise, and the dual sided fire place was screened appropriately. The first aid kit contains all necessary elements. The two fire extinguishers were mounted, charged, and serviced on December 3, 2025. The auditory devices and smoke/carbon monoxide detectors were tested and operational in all areas. Facility maintains emergency food and water. A working telephone (949-837-3737) was tested and remains available. Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the entry way in the correct size.

LPA reviewed six residents and two personnel files. A discrepancy was noted with the staff records as two of two staff did not have their Health Screeninig Report (LIC503) and Tuberculosis (TB) tests on file as they were accidentally discarded per Admin. Present staff are background cleared and associated to the facility. Staff met their annual 20 hour training. The Emergency Disaster Plan (LIC610E) was reviewed. The disaster supplies noted on the plan are available. Disaster (fire) drills are conducted three times this year, January, March, and May 2026 per log. Medications were audited for three of six residents. No discrepancies were found with medication administration and documentation.

LPA consulted on the following: to deep clean kitchen appliances and refrigerator as well as all bathrooms, to ensure staff obtains and completes the health screening report/TB tests, to organize/maintain resident records/files, and to conduct disaster drills accounting various emergency scenarios besides fire drills.

Based on the observations made during today's visit, a deficiency is being cited and Technical Advisories are being issued

An exit interview was conducted with Administrator Shahin Mokhtazad, and a copy of this report including the appeals rights were provided at exit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/22/2026 12:31 PM - It Cannot Be Edited

Created By: Jessica Cho On 05/22/2026 at 11:40 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EVER CARE	FACILITY NUMBER: 306005210
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two of two staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2026
	Plan of Correction
1 2 3 4	Admin stated that the LIC503 will be submitted to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:

	Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026

LIC809 (FAS) - (06/04)

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