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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006251
Report Date: 01/11/2024
Date Signed: 01/11/2024 12:43:27 PM


Document Has Been Signed on 01/11/2024 12:43 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 RO, 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:
92869
CAPACITY:6CENSUS: 6DATE:
01/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Tawsique Salam, House Manager
Tamanna Rahman, Administrator		TIME COMPLETED:
01:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a case management visit at the facility during a complaint investigation visit made regarding the previously licensed entity Happy Living Home Care - 306005953, with reference number 22-AS-20240105105835.

During the visit, LPA accompanied with facility staff conducted a tour of the facility and issued two Technical Assistance Advisory Notes to the licensee.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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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