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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005374
Report Date: 06/21/2022
Date Signed: 06/21/2022 02:14:43 PM


Document Has Been Signed on 06/21/2022 02:14 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, 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: 6DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Shahin MokhtarzadTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced required annual inspection focusing primarily on the Infection Control. At 12:15 pm, LPA was greeted and granted entry by Caregiver Eugene Dulatre after completing the Coronavirus 2019 (COVID-19) screening procedure. As of today, there are no active COVID-19 cases in the facility. Facility screens temperature for all visitors on a sign in sheet prior to entry. LPA observed the required COVID-19 precautionary signs posted by the door of the main entrance and around the facility. Tthe PUB475 See Something, Say Something poster was observed by the entryway in the size of 8.5"x11," and the Administrator's Certificate for Shahin Mokhtarzad expires on 11/20/2023.

Around 12:28 pm, LPA toured the interior and exterior portions of the facility with Caregivers Dulatre and Michael "Milo" Reyno. The Administrator (Admin) Shahin Mokhtarzad arrived at the facility around 12:35 pm and assisted with the tour. The facility is a single level structure and licensed for six non-ambulatory residents; and has a hospice waiver for two. Currently, there a total of six residents in the facility of which one is in hospice care. Facility appeared clean and sanitary in all areas observed. All five bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxides, and auditory exit alarms tested operational. The restrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water measured at 122.9 degrees Fahrenheit in Restroom #1; 120.9 degrees Fahrenheit in Restroom #2; and 118.2 degrees Fahrenheit in Restroom #3. LPA observed hand washing signs, paper towels, and hand soaps in all three restrooms. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the residents in care. The fire extinguisher was charged and mounted in the kitchen/dining room.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: EVER CARE
FACILITY NUMBER: 306005374
VISIT DATE: 06/21/2022
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For the exterior portion, LPA observed patio furniture under ample shading, and the grounds were free of tripping hazards. The side gates were self-closing and self-latching. LPA observed the emergency disaster and evacuation plans. Facility had back-up emergency food and water supply. The First Aid Kit had all the required components except the manual. The facility had sufficient PPEs and incontinence supplies stored in the hallway cabinet. Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed.

LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. Per Admin, three out of the six residents have access to their own iPad and a smart phone is provided for the remaining three out of the six residents upon request.



LPA consulted the following: To enlarge the PUB475 See Something, Say Something poster in the size of 20"x26", to purchase a current edition of the first aid manual, and to pay the outstanding balance of the annual licensing fees in the amount of $495.00

LPA reviewed the COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. Three Advisory Notes (LIC9102) were issued during the visit, and the licensee will follow-up with the corrections. An exit interview was conducted with Administrator Shahin Mokhtarzad, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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