306006251-5-24-2024-22-AS-ARJR-D5KP2L-20240524105608

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006251
Report Date: 05/24/2024
Date Signed: 05/24/2024 10:56:14 AM

Document Has Been Signed on 05/24/2024 10:56 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
ORANGE COUNTY RO, 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:	92869
CAPACITY:	6	CENSUS: 6	DATE:	05/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Tawsique Salam-Manager, Tamanna Rahman-Administrator		TIME COMPLETED:	10:59 AM

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Manager Tawsique Salam. Administrator (AD) Tamanna Rahman arrived shortly after.

For today’s visit, LPA observed a total of six residents in care and two staff members on duty.

LPA observed the Administrator's Certificate for facility AD Tamanna Rahman which expires on September 15, 2024.

LPA Ramirez toured the interior and exterior portions of the facility with Manager Salam. The facility is a two-story structure and is licensed for six non-ambulatory residents, of which six may be on hospice and zero bedridden. There are a total of six bedrooms, of which four are resident bedrooms and two staff bedrooms. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of three restrooms of which one is for staff and two are for residents. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 109.4-111.2 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and one was located by the dining room and one by the staff's bedrooms hallway.

CONTINUED ON LIC809-C..

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 306006251
	VISIT DATE: 05/24/2024

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LPA Ramirez observed the emergency disaster and evacuation plan, which is posted by the resident's bedrooms hallway. LPA observed that the First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Ramirez observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard, which both are self-closing and self-latching. No bodies of water were observed.

LPA reviewed four resident files and two staff files. LPA interviewed residents and staff present.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Rahman.

A copy of this report was provided at the time of exit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

LIC809 (FAS) - (06/04)

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