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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006251
Report Date: 02/16/2023
Date Signed: 02/16/2023 01:13:29 PM

Document Has Been Signed on 02/16/2023 01:13 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:EVERGREEN ADULT HOME CAREFACILITY NUMBER:
306006251
ADMINISTRATOR:RAHMAN, TAMANNAFACILITY TYPE:
740
ADDRESS:362 N SWIDLER STTELEPHONE:
(951) 893-0859
CITY:ORANGESTATE: CAZIP CODE:
92864
CAPACITY: 6CENSUS: 5DATE:
02/16/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Tamanna RahmanTIME COMPLETED:
12:35 PM
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Kimberly Lyman made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPAs arrived at the facility and were greeted and granted entry by designated Administrator (AD) Tamanna Rahman. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (6) ambulatory, (0) non-ambulatory, and (0) bedridden residents was received by CCL on 10/14/2022.

Structure:
The facility is a two-story home with four resident bedrooms, two bathrooms, living room, kitchen, and an attached two car garage on the first floor and staff quarters upstairs. LPAs observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entrance of the facility. There is a back yard with one exit gate on the side of the house. There is a shaded seating area in the backyard. No bodies of water were observed. LPA did not observe any obstacles or hazards in the backyard. Facility has a generator and it will be stored in the garage.

Bedrooms Bedrooms
All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets.

Signal system
There is no signal system.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the garage.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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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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: EVERGREEN ADULT HOME CARE
FACILITY NUMBER: 306006251
VISIT DATE: 02/16/2023
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Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements, however, was observed to be missing scissors.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in the garage.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
Bingo, board and card games will be kept for resident use. The facility will encourage outings, walks, and arts and crafts.

Fire clearance:
Was approved by a fire inspector of Orange City Fire Department on 01/25/2023. No special conditions noted.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:


The second story of the facility will be used as staff quarters.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 109.5 degrees Fahrenheit.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: EVERGREEN ADULT HOME CARE
FACILITY NUMBER: 306006251
VISIT DATE: 02/16/2023
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Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Two out of four burners on gas stove were operational. Three refrigerators, oven, dish washer, microwave, washer, and dryer are operational.

Licensee to address the following corrections by 03/16/2023:

· Two out of four burners on gas stove are not operational. All stove burners must be operational.

· The door to bathroom one has a door stopper placed mid-way up on side of the door scraping the paint, causing it to chip. Door must operate as designed.

· Flooring in bathroom one is missing a piece of tile behind the toilet and there is discoloration along the baseboard.

· There is a tape cover measuring about 8x10 in. on one of the living room walls covering a hole.

· Nails, bolts, and power tools were observed laying unattended in the backyard by the side gate. All sharps and power tools must be made inaccessible.

· Light switch located in the stairway has a gap between the switch and cover.

· There are multiple missing tiles on the kitchen bar and by the kitchen sink.

· The first aid kit was observed to be missing scissors.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
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: EVERGREEN ADULT HOME CARE
FACILITY NUMBER: 306006251
VISIT DATE: 02/16/2023
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The facility is not ready to be licensed. Licensee to contact LPA when corrections are complete.

An exit interview was conducted with AD and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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