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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920026
Report Date: 07/17/2024
Date Signed: 07/17/2024 03:15:24 PM


Document Has Been Signed on 07/17/2024 03:15 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: 4DATE:
07/17/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator- Tatiana MaliucovTIME COMPLETED:
02:15 PM
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On 07/17/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct an annual required and post licensing visit. LPA met with Administrator Tatiana Maliucov and explained the purpose of the visit.

For more information on the post licensing visit, please see LIC809 for Required - 1 Year dated 07/17/24.

No deficiencies cited for the post licensing visit.

Exit interview conducted a copy of the report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
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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