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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005824
Report Date: 10/28/2021
Date Signed: 10/28/2021 12:59:15 PM

Document Has Been Signed on 10/28/2021 12:59 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:EVERDEEN HOMESFACILITY NUMBER:
306005824
ADMINISTRATOR:MENDOZA, ALVIN C.FACILITY TYPE:
735
ADDRESS:1210 N. GROTON ST.TELEPHONE:
(714) 261-4530
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 4CENSUS: 3DATE:
10/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Alvin MendozaTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the annual required inspection (mitigation). LPA was greeted and granted entry by staff. Administrator Alvin Mendoza arrived at 12:00 noon. LPA explained the reason for the visit. Facility has 4 bedrooms, 2 bathrooms and a 2 car detached garage. LPA and Administrator toured the facility. LPA observed all the client bedrooms had the required furnishings. LPA observed both bathrooms were clean and operational. LPA inspected the kitchen. LPA observed the facility has a 2 day supply of perishable food and a 7 day supply of non-perishable food on hand. LPA observed medication is kept locked in a cabinet. LPA observed the knives are kept locked in a kitchen drawer. LPA observed the fire extinguisher in the kitchen is fully charged. LPA inspected the first aid kit. The first aid kit had all the required elements. LPA inspected the garage and backyard. The garage is kept locked and used for storage. The backyard has a covered patio and a table and chairs to sit outside. The single exit gate is operational. No bodies of water observed. No obstacles or hazards observed in the backyard or the garage. Smoke detectors/carbon monoxide detectors tested operational. Facility mitigation plan is pending approval. No deficiencies are being cited as a result of today's visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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