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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920026
Report Date: 08/31/2023
Date Signed: 08/31/2023 02:26:10 PM


Document Has Been Signed on 08/31/2023 02:26 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:EVERGREEN PALMS SENIOR CARE LLCFACILITY NUMBER:
345920026
ADMINISTRATOR:MALIUCOV, TATIANAFACILITY TYPE:
740
ADDRESS:7013 ROLLINGWOOD BLVDTELEPHONE:
(916) 205-2718
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 0DATE:
08/31/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator: Tatiana MaliucovTIME COMPLETED:
02:40 PM
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On 08/31/2023 at 1:30 PM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Pre-Licensing Inspection utilizing the inspection tool. LPA met with Administrator, Tatiana Maliucov, and explained the purpose of the visit. There are currently no residents at the facility. The facility is approved for one (1) bedridden resident and five (5) non-ambulatory residents.

At 1:40 PM, LPA and administrator toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, garage and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed five (5) residents' bedrooms and one (1) full and two half bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. Sharps and knives are locked. The hot water temperature was measured in the kitchen at 111 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 05/2023. LPA observed medications to be locked and inaccessible to residents in care. LPA observed required Licensing posters posted throughout the facility.

Component III has been completed at this time with administrator.

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit interview was conducted with Licensees and a copy of this report was emailed to the facility.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
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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