198200705-3-12-2026-11-AS-EMAZ-DSS2FF-20260402172129

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198200705
Report Date: 03/12/2026
Date Signed: 03/12/2026 05:12:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/03/2026 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20260303092018

FACILITY NAME:	EVERGREEN HAVEN		FACILITY NUMBER:	198200705
ADMINISTRATOR:	ARLENE FELICIANO		FACILITY TYPE:	740
ADDRESS:	2513 WEST 168TH STREET		TELEPHONE:	(310) 630-0817
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 6	DATE:	03/12/2026
		UNANNOUNCED	TIME BEGAN:	11:26 AM
MET WITH:	Arlene Feliciano		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff are financially abusing resident
Staf are not providing resident with adequate accommodations
Staff are inappropriately tapping resident's phone

INVESTIGATION FINDINGS:

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On 03/12/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint 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 investigation consisted of the following:
During today’s visit, LPA interviewed R1, interviewed Staff S1, and delivered findings.
During the initial visit conducted on 03/11/2026, LPA inspected the facility, interviewed Staff S1-S3, interviewed Residents R1-R6, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Admission Agreement (dated 10/05/2025), Admission Policies & Procedures (dated 10/05/2025), Physician’s Report (dated 10/01/2025), Needs and Service Plan (dated 10/04/2025), Assessments (10/04/2025), Appraisals (dated 10/04/2025), Identification and Emergency Information, Personal Rights of Residents in Privately Operated Residential Care Facilities for the Elderly (dated 10/04/2025), Unusual Incident/Injury Report (dated 10/05/2026 & 03/06/2025), and staff’s Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 11-AS-20260303092018

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/12/2026

NARRATIVE

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The investigation revealed the following:
Allegation: Staff are financially abusing resident.
The allegation alleges that the staff have spent all of their funds.
During record review, LPA received and reviewed staff’s Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders. Additionally, LPA received and reviewed resident’s Personal Rights of Residents in Privately operated Residential Care Facilities of the Elderly that states, residents have the right “to be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.”
During the inspection, LPA observed the Personal Rights of residents posted near the entrance of the facility.
During interviews with Residents R1-R6, were asked if the staff are financially abusing them, six (6) out of six (6) stated no, staff are not financially abusing them. Additionally, Residents R1-R6, were asked if staff have access to their banking accounts, six (6) out of six (6) stated no, staff do not have access to their banking accounts.
During interviews with Staff S1-S3, were asked if any of the residents have been financially abused by a staff at the facility, three (3) out of three (3) stated none of the residents have been financially abused.

Allegation: Staff are not providing resident with adequate accommodations.

The allegation alleges that the resident is staying in a closet.
During record review, LPA received and reviewed the initial Fire Clearance, and facility sketch that indicates the rooms R1-R6 are residing in are approved for residents. Additionally, LPA received and reviewed resident’s Personal Rights of Residents in Privately Operated Residential Care Facilities for the Elderly, that states residents have the right “to be accorded safe, healthful and comfortable accommodations, furnishings and equipment.”
As part of the facility inspection, LPA inspected all resident rooms and observed they accommodate a bed, dresser, nightstand, chair, and has storage space for resident’s personal belongings.
During interviews with Residents R1-R6, were asked how they like their accommodations, six (6) out of six (6) stated their rooms are okay.
During interviews with Staff S1-S3, were asked were asked if residents are provided with a room to reside in, three (3) out of three (3) stated residents are provided with a private room.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20260303092018

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/12/2026

NARRATIVE

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Allegation: Staff are inappropriately tapping resident’s phone.
The allegation alleges that the staff have tapped the phone of a resident.
During record review, LPA received and reviewed resident’s Personal Rights of Residents in Privately Operated Residential Care Facilities for the Elderly that states, resident’s have the “to have reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the internet, and meetings of resident and family groups.”
During the visit, LPA observed staff assist a resident with making a phone. The staff assisted with dialing the number, handed the phone to the resident, told the resident to call if they need assistance when they are done, exited the room, and closed the door. Additionally, LPA observed a resident visiting with their family privately in the living room.
During interviews with Staff S1-S3, were asked if a resident’s phone has been tapped, three (3) out of three (3) stated no, a resident’s phone has not been tapped. Additionally, Staff S1-S3 were asked how residents are provided privacy while on a telephone call, three (3) out of three (3) stated they help them dial the number, if needed, then exit the room and close the door.
During interviews with Residents R1-R6, were asked if they are provided with privacy while on the telephone, six (6) out of six (6) stated yes, they are provided with privacy during telephone calls. Additionally, LPA asked Staff S1-S6 if the any of the phones in the facility are tapped.

During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated.

During today's visit LPA did not observe or cite any deficiencies.
An exit interview was conducted with Administrator, Arlene Feliciano, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC9099 (FAS) - (06/04)

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