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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005210
Report Date: 07/16/2021
Date Signed: 07/16/2021 10:28:00 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/16/2021 10:28 AM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:EVER CAREFACILITY NUMBER:
306005210
ADMINISTRATOR:MOKHTAZAD, SHAHINFACILITY TYPE:
740
ADDRESS:24611 SPARTAN STREETTELEPHONE:
(949) 616-4785
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shahin MokhtazadTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival, LPA met Caregivers Mabella and Arnulfo Suarez. LPA explained the purpose of the visit. Administrator Shahin Mokhtazad was contacted via telephone and she arrived at approximately 10:00 am.

During the visit LPA toured the facility inside and out with Mabella and then Shahin . LPA observed Covid signage at front entrance of facility as well as a sanitization station. Facility has required Department postings. LPA observed a copy of Administrator Certificate for Shahin Mokhtazad that expires 11/20/21. LPA toured all resident rooms. Rooms were clean and sanitary. Restrooms and rooms observed contained ample supplies of hand sanitizer, soap, wipes, gloves and paper towels. LPA observed outside visitation area with ample shading. There were 6 resident's present. Three resident's were having breakfast and 3 other's were still in their beds sleeping. Licensee has required Mitigation plan and Emergency Disaster Plan. LPA also observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted about the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA discussed sign in and screening procedures for visitors. LPA advised the importance of mask wearing for staff and handwashing for staff and residents.

No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Shahin Mokhtazad.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2021
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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