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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200705
Report Date: 12/19/2025
Date Signed: 12/19/2025 04:56:54 PM

Document Has Been Signed on 12/19/2025 04:56 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:EVERGREEN HAVENFACILITY NUMBER:
198200705
ADMINISTRATOR/
DIRECTOR:		ARLENE FELICIANOFACILITY TYPE:
740
ADDRESS:2513 WEST 168TH STREETTELEPHONE:
(310) 630-0817
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 6DATE:
12/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:34 PM
MET WITH:Arlene FelicianoTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 12/19/25 at 1:20pm, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Administrator, Arlene Feliciano, and the purpose of today's visit was explained. LPA was granted entry into the facility. The facility is licensed for six (6) non-ambulatory residents ages 60 and over with an approved Hospice Waiver for one (1) resident.

Structure/Physical Plant The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) residents’ rooms, staff room, four (4) bathrooms, living room, sitting area, dining area, kitchen and outside covered patio area. LPA observed all walkways outside of the facility to be clean, clear, and free of debris, obstructions and hazards. LPA did not observe any bodies of water on the premises.

Bedrooms LPA inspected all residents’ bedrooms and observed them to be clean and in good repair. All rooms were observed with the required furniture including a bed, dresser, nightstand, chair, and ample storage space for resident’s personal belongings. All beds were observed to have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. All linens were observed in good repair. LPA observed an adequate supply of linens. All bedrooms were observed to have ample lighting.

Bathrooms LPA inspected all bathrooms and were found to be within Title 22 regulations. All bathrooms were observed clean, operable, and in good repair. All bathrooms had secured safety handrails, shower chairs, and a nonskid mat. The showers were free of mildew and/or mold. LPA observed an ample supply of personal hygiene products and towels in good repair. The water temperature in the bathrooms measured 114.7-degrees, 114.5-degrees, 118.7- degrees and 115.1-degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: EVERGREEN HAVEN
FACILITY NUMBER: 198200705
VISIT DATE: 12/19/2025
NARRATIVE
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Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed an ample supply of cookware, dining ware, and cutlery in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods properly labeled, dated, and stored. All appliances were observed operable. The water temperature measured 108.1-degrees Fahrenheit. LPA observed all sharps secured in a locked drawer in the kitchen and are inaccessible to residents. LPA observed cleaning supplies secured in a cabinet under the kitchen sink and are inaccessible to residents.

Common Rooms LPA inspected all common rooms and observed the facility appropriately furnished. The living room has a large couch and chairs to accommodate all residents. The sitting area has multiple chairs and a couch to accommodate residents. LPA observed a fireplace screened and inaccessible to residents. The dining room has a large rectangular table with six chairs to accommodate all residents. LPA observed games, puzzles, magazines, and books stored in the dining room for residents. The facility was maintained at a comfortable temperature. LPA observed all walkways and hallways in the facility to be clean, clear, and free of hazards.

Medications LPA observed centrally stored medications secured in a locked cabinet in the kitchen and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medications and Medication Administration Records (MARs) for four (4) residents. LPA observed the residents’ MARs and medication are consistent with properly documented records.

Files LPA reviewed six (6) Resident files and observed the files contain the required documents. LPA reviewed the Administrator and two (2) staff files and observed they contained the required documents, clearance, and training. LPA reviewed the staff training logs and observed staff have the required training hours.


Safety LPA observed all required signs and documents posted throughout the facility. LPA reviewed and received a copy of the facilities Liability Report which expires on 12/29/25 through Acord. Smoke detectors and Carbon Monoxide detectors are operable. LPA observed two (2) fully charged fire extinguishers last serviced on 04/25/25. The last facility inspection from the Torrance Fire Department was in October 2025. LPA inspected the First Aid Kit and found it contained the required items. The last emergency drill was conducted on 09/21/25. The facility has a working landline telephone. There are no firearms or ammunition stored at the facility.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: EVERGREEN HAVEN
FACILITY NUMBER: 198200705
VISIT DATE: 12/19/2025
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Infection Control Upon entry LPA observed a sign-in for visitor and a hand sanitizing station at the front door. LPA observed mandated infection control signs posted throughout the facility. LPA observed a 30-day supply of Personal Protective Equipment (PPE).

Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D.

An exit interview was conducted with Administrator, Arlene Feliciano, and a copy of this report and Appeals Rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2025 04:56 PM - It Cannot Be Edited


Created By: Wendy Gibbs On 12/19/2025 at 04:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN HAVEN
FACILITY NUMBER: 198200705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in three (3) out of three (3) Staff S1-S3 had CPR cards that expired on 10/17/2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2025
Plan of Correction
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Licensee will ensure all staff CPR cards are up to date. Licensee will email copy of the expired CPR cards to LPA via email, at Wendy.Gibbs@dss.ca.gov, before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Eva M Alvarez
NAME OF LICENSING PROGRAM MANAGER:
Wendy Gibbs
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2025


LIC809 (FAS) - (06/04)
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