306006251-3-20-2023-22-AS-CGUZ-CQ4MT9-20230320095310

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006251
Report Date: 03/20/2023
Date Signed: 03/20/2023 09:54:20 AM

Document Has Been Signed on 03/20/2023 09:54 AM - 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 CARE		FACILITY NUMBER:	306006251
ADMINISTRATOR:	RAHMAN, TAMANNA		FACILITY TYPE:	740
ADDRESS:	362 N SWIDLER ST		TELEPHONE:	(951) 893-0859
CITY:	ORANGE	STATE: CA	ZIP CODE:	92864
CAPACITY:	6	CENSUS: 5	DATE:	03/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Tamanna Rahman		TIME COMPLETED:	10:10 AM

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Licensing Program Analysts (LPAs) Claudia Gutierrezj and Kimberly Lyman made an announced visit to the facility for purpose of conducting a pre-licensing inspection visit to follow up on corrections identified during visit on 02/16/2023. LPAs arrived at the facility and was greeted and granted entry by designated Administrator (AD) Tamanna Rahman and House Manager Tawsique Salam. 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.

At 9:10 a.m. LPA toured the facility and observed the following:

Five out of five stove burners on gas stove were operational.
The door stopper placed on bathroom one door mid-way up scraping the paint, causing it to chip has been removed.
Bathroom one is no longer missing piece of tile behind the toilet and discoloration along the baseboard has been addressed and was not observed.
Tape cover measuring about 8x10 in. on one of the living room walls covering a hole has been removed and hole in the wall has been patched.
Nails, bolts, and power tools previously observed laying unattended in the backyard by the side gate have been removed.
LPA observed there are no broken or missing tiles on the kitchen bar or by the kitchen sink.
First aid kit was observed to have scissors and all other required elements.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

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: 03/20/2023

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Licensee to address the following corrections:

Light switch located in the stairway has a gap between the switch cover in the wall.
Baseboard along the walls upstairs is missing and there is a gap between the flooring and walls.
In the entrance way to the facility fresh dry wall was observed to still be drying.

All noted items will be addressed by 4/20/2023.

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

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC809 (FAS) - (06/04)

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