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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425140
Report Date: 04/21/2022
Date Signed: 04/22/2022 08:38:52 AM


Document Has Been Signed on 04/22/2022 08:38 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:EVERGREEN CHATEAUFACILITY NUMBER:
336425140
ADMINISTRATOR:MAHBOUBEH ARABSHAHIFACILITY TYPE:
740
ADDRESS:32913 NORTHSHIRE CIRCLETELEPHONE:
(951) 303-1051
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:6CENSUS: 0DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Licensee- Mahboubeh ArabshahiTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by licensee Mahboubeh Arabshahi, who was informed of the purpose of the visit. At the time of visit there was 1 staff and 0 residents present. The facility currently has zero positive or suspected Covid-19 cases. During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings at the facility and advised licensee to post them around the facility by the end of the visit. This will be documented on an LIC9102TA. A single entry point was designated where symptoms screenings and temperature checks will occur daily. The facility had a plan in place to monitor residents regularly for any changes in condition. The facility had an adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels) in all restrooms. Common areas such as dining rooms and activity rooms have been modified with social distancing and masking policies. There are designated isolation rooms and a plan in place to monitor and attend to those in the isolation rooms. LPA observed a sufficient 30-day supply of PPE equipment. The facility also has a designated infection control lead and a plan in place to clean and disinfect the highly touched surfaces. LPA advised Licensee to provide the department with a copy of the facility Mitigation plan. Licensee was able to complete mitigation plan before the end of the visit and LPA was able to review it and approve it. This will be documented on an LIC 9102TA and LIC 812.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EVERGREEN CHATEAU
FACILITY NUMBER: 336425140
VISIT DATE: 04/21/2022
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During the tour of the facility LPA noticed Room 3 and Room 4 did not have a bed in them. However, the licensee did have chairs, shared nightstand and a reading lamp in the bedrooms. Licensee was able to show LPA available beds at the facility that could accommodate the total capacity of 6 residents. This will be documented on an LIC 812.

There were no deficiencies noted at the time of the visit.

An exit interview was conducted, and a copy of this report was reviewed and provided to facility licensee, Mahboubeh Arabshahi.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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