<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006251
Report Date: 04/27/2023
Date Signed: 04/27/2023 09:35:21 AM


Document Has Been Signed on 04/27/2023 09:35 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 CAREFACILITY NUMBER:
306006251
ADMINISTRATOR:RAHMAN, TAMANNAFACILITY TYPE:
740
ADDRESS:362 N SWIDLER STTELEPHONE:
(951) 893-0859
CITY:ORANGESTATE: CAZIP CODE:
92864
CAPACITY:6CENSUS: 5DATE:
04/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tamanna RahmanTIME COMPLETED:
09:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection to follow up on corrections identified during visit on 03/20/2023. LPA arrived at the facility and was greeted and granted entry by designated Administrator (AD) Tamanna Rahman. House Manager Tawsique Salam was also present. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by CCL on 10/14/2022.

At 9:00 a.m. LPA toured the facility and observed the following:

· Light switch located in the stairway has been aligned and no longer has a gap between the switch cover and the wall.

· Baseboard along the walls upstairs has been installed and there is no longer a gap between the flooring and walls.

· In the entrance way of the facility dry wall previously observed to be drying has been painted over and is seamless to wall.

All noted items from visit on 03/20/2023 have been addressed. The facility is ready to be licensed.

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

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1