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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005374
Report Date: 06/30/2021
Date Signed: 06/30/2021 03:27:31 PM

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:EVER CAREFACILITY NUMBER:
306005374
ADMINISTRATOR:MOKHTARZAD, SHAHINFACILITY TYPE:
740
ADDRESS:24985 HENDON STTELEPHONE:
(949) 616-4785
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 0DATE:
06/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Shahin MokhtarzadTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducting an unannounced visit for the purpose of conducting a required annual inspection visit. LPA was greeted at the door by Licensee/Administrator and granted entry. LPA met with Administrator and explained the nature of the visit.

Upon entry LPA immediately began the tour of the facility accompanied by Administrator. The facility currently has no residents in care. Administrator had advised LPA that facility was going to remodel the kitchen and was to temporary relocate residents to a licensed facility for about a month. LPA was informed that one resident permanently moved out of the facility, family moved resident to another facility and will not be returning. Remaining resident was relocated on June 26, 2021 to a licensed facility Silver Coast Living/306005784 for one months until the remodel is done. Facility has a check in station in the main entrance of the facility to adhere to covid check in guidelines. Facility keeps documentation in regard to covid for all staff and residents. Facility has covid precautionary posting through out the facility as well as all required Department postings. Facility has an active covid-19 prevention plan in place for the safety of all residents in care. LPA observed ample supply of emergency food and water as well as first aid kits in the facility. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has sanitation precaution in place through out the facility and all common spaces of the facility. Facility has a shaded space in the backyard used for visitation. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation as needed. Facility bedrooms are currently single occupancy.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
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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