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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006506
Report Date: 05/31/2024
Date Signed: 05/31/2024 02:14:34 PM

Document Has Been Signed on 05/31/2024 02:14 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EVERGREEN ADULT HOME CARE AT TUSTINFACILITY NUMBER:
306006506
ADMINISTRATOR/
DIRECTOR:		RAHMAN, TAMANNAFACILITY TYPE:
740
ADDRESS:14611 DANBERRY CIRCLETELEPHONE:
(951) 893-0859
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 2DATE:
05/31/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator/Licensee Tamanna RahmanTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived and was greeted and granted entry by Administrator/Licensee Tamanna Rahman and Manager Designee Tawsique Salam. Assistant Administrator Latif Rahman and Manager of Facility Affairs Alexis Deseo were also present during inspection. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by Community Care Licensing (CCL) on 1/26/2024.

The facility is a two-story home. The first floor houses three shared resident bedrooms, two bathrooms, living room, family room, dining room, kitchen, music room, staff room, covered patio, backyard and 2-car garage. The second floor houses the management office, three staff rooms, one bathroom and loft. The second floor is inaccessible to residents.



Resident Bedrooms have all the necessary requirements including bed, chair, storage for clothing and ample lighting. LPA observed all windows were screened.

All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 112.4 degrees Fahrenheit and 113.9 degrees Fahrenheit in the Resident bathrooms.

LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone.

Medication and First-Aid Kit will be locked in a cabinet in the dining room. Resident & Staff Files will be locked in the management office on the second floor.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: EVERGREEN ADULT HOME CARE AT TUSTIN
FACILITY NUMBER: 306006506
VISIT DATE: 05/31/2024
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The fire clearance was approved by a fire inspector of Orange County Fire Authority on 3/12/2024.

LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and are stored and locked in cabinets in the garage.

A supply of extra linens is stored in a closet in the hallway as well as the garage

Emergency Phone Numbers, Exit Plan, Activity Calendar and Menu are all posted and available for review. LPA observed other necessary postings in the living room and dining room.

Smoke and Carbon Monoxide detectors are stationed throughout the home and are wired together. Both types of detectors were tested and noted as operational.

Operational appliances include a gas stove, oven, two refrigerators, freezer, dishwasher, microwave, washing machine and dryer.

LPA provided the Component III presentation to offer information and resources regarding maintaining facility compliance.

The designated AD was notified that the final application approval will be issued by the Centralized
Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to
designated AD.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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