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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005824
Report Date: 10/10/2024
Date Signed: 10/10/2024 03:25:37 PM

Document Has Been Signed on 10/10/2024 03:25 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/
DIRECTOR:		MENDOZA, ALVIN C.FACILITY TYPE:
735
ADDRESS:1210 N. GROTON ST.TELEPHONE:
(714) 261-4530
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 4CENSUS: DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:48 PM
MET WITH:Alvin Mendoza - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by Enrico Mendoza, Caregiver. Caregiver, Ildefonso Caday joined the inspection after Caregiver Mendoza's shift ended. LPA spoke with administrator Alvin Mendoza via phone call and explained the purpose of the inspection.

The facility is one-story home with four client bedrooms, two client bathrooms, kitchen, dining room, living room, staff room, detached 2-car garage and backyard. Facility appears clean, safe and sanitary. LPA observed the facility has the necessary postings posted on the walls. All client rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for clients in hallway cabinets. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was serviced on 8/16/2024 according to the attached service tag. Smoke/Carbon Monoxide detector were tested and noted as operational. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen. Knives are locked up separate from toxic chemicals. Medication for each client is kept locked in a cabinet in the kitchen. Exit gate is unlocked. LPA observed exit gate to be unobstructed. LPA reviewed three client files and three staff files. LPA reviewed the disaster drill log. LPA reviewed client P&I. Based on P&I review, LPA determined client funds were co-mingled with petty cash. A citation is being issued. LPA also reviewed medication for three clients. LPA interviewed one staff and one client.



Based on today's inspection, one citation is being issued. An exit interview was conducted and a copy of
this report, deficiency page, technical assistances and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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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Document Has Been Signed on 10/10/2024 03:25 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/10/2024 at 03:04 PM
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: EVERDEEN HOMES
FACILITY NUMBER: 306005824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(e)
Safeguards for Cash Resources, Personal Property and Valuables
(e) Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to client P&I funds being co-mingled with facility petty cash which poses a potential personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Administrator stated they will conduct a training with staff to ensure they know proper protocol for managing client P&I and records. Administrator stated they will document the topics covered in the training, staff in attendance and date/time of training. Administrator stated they will send the documentation related to this training to the LPA via email by the assigned POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
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