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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003773
Report Date: 11/08/2024
Date Signed: 11/08/2024 12:16:02 PM

Document Has Been Signed on 11/08/2024 12:16 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EVERGREEN CARE HOMEFACILITY NUMBER:
306003773
ADMINISTRATOR/
DIRECTOR:		HAERYUN CHOFACILITY TYPE:
740
ADDRESS:4715 ST. ANDREWS AVENUETELEPHONE:
(562) 480-9453
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 6DATE:
11/08/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Haeryun ChoTIME VISIT/
INSPECTION COMPLETED:
12:32 PM
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On 11/8/2024, LPA Mason arrived at the facility for the purpose of conducting a Plan of Corrections visit. LPA arrived at the facility and was greeted and granted entry by staff. LPA met with Administrator Haeryun Cho and explained the nature of the inspection.

On 11/6/2024, the facility received a deficiency for knives not being locked.

Based on observations today, LPA determined the facility had the knives locked in the garage. AD requested an extension to complete the training associated with the plan of correction. LPA stated the plan of correction will be due Monday 11/11/2024 by 5:00pm.

LPA provided Administrator with guidance on creating a report in Microsoft Word

Based on today's visit, no deficiencies are being issued. This report was reviewed with facility staff and provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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