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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005824
Report Date: 10/27/2023
Date Signed: 10/27/2023 02:10:12 PM

Document Has Been Signed on 10/27/2023 02:10 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 ASC, 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: 4DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Alvin Mendoza - AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into facility by DSP Demetrio Fernandez. LPA observed construction to be taking place at the facility. DSP Fernandez called Administrator Alvin Mendoza. AD stated that on 10/26/2023, the day before LPA’s inspection, staff noticed water filling one of the sinks. Staff called a plumber. Plumber let the facility know that a pipe was leaking, which is why a construction team was at the facility the following day. Construction is occurring while other clients are away day program and will conclude for the day once Residents return from day program. One restroom and the washing machine are non-operational for the day due to construction. Washing machine will be operational by the end of the day. The restroom will be operational on 10/28/2023. AD arrived at the facility at approximately 1:30p.

The facility is a one-story home with four client bedrooms, two bathrooms, kitchen, dining room, living room, sun room, backyard and detached garage. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. The operational restroom has paper towels and hot water measuring at 105 degrees Fahrenheit. LPA observed facility has emergency food and water supply. Activity supplies including board games, a treadmill, an arcade and a television are housed in the sun room. Medication for two residents is kept in locked cabinets in the kitchen. The other residents do not take medication. A supply of extra linen was observed in the hallway closet. Extra hygiene supplies were observed in the garage. The fire extinguisher was observed to be fully charged. The service tag indicated the extinguisher was last serviced on 8/4/23. The exit gate is unlocked and self-latching. LPA reviewed two of four the resident files. Only two residents take medication. LPA reviewed all medication. LPA interviewed one resident who returned during the inspection. The other residents were not available for interview.

No deficiencies are being noted during today's visit. An exit interview was conducted with Administrator Alvin Mendoza and staff present and a copy of this report was provided to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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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