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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005374
Report Date: 07/10/2025
Date Signed: 07/10/2025 03:16:38 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2024 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241107085641
FACILITY NAME:EVER CAREFACILITY NUMBER:
306005374
ADMINISTRATOR:MOKHTARZAD, SHAHINFACILITY TYPE:
740
ADDRESS:24985 HENDON STTELEPHONE:
(949) 616-4785
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 6DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Shahin MokhtarzadTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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-Facility did not meet the residents needs
-Facility is not abiding by the admission agreement
-Facility did not ensure that resident falls were reported to the Department.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrive at facility was greeted at the door and granted entry. LPA spoke with Shahin Mokhtarzad, Administrator and explained the purpose of the visit.

Findings are based upon this investigation which included facility file review, interviews conducted with staff, and residents.
It is alleged the facility did not meet residents’ needs. Based on file review resident (R1) expired at the facility on October 28, 2024, and LPA was unable to interview. Record review for R1 revealed that LIC602 physicians report page 4 number 14i. R1 was able to communicate needs. Interviews conducted revealed the following: 3 of 3 staff stated that R1 was very vocal and would express needs, R1 would let staff

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
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 2
Control Number 22-AS-20241107085641
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: EVER CARE
FACILITY NUMBER: 306005374
VISIT DATE: 07/10/2025
NARRATIVE
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know when they needed something. Staff stated that R1 was able to use the call button that would alert staff when they needed assistance. R1 would ask staff to trim their hair, and the Administrator buys the residents clothes when they need them instead of asking the family for clothes. Families are welcome to bring residents new clothes, but Administrator doesn’t depend on families and goes and buys them clothes as needed. An interview with 4 of 4 residents stated that they always get their needs, always met by staff and don’t have an issue.
It is alleged that facility is not abiding by the admissions agreement. R1’s records review revealed that R1 and or responsible parties signed Admission agreements that included a section regarding Overnight staff which states “Overnight wake staff is provided at Ever Care when prescribed by a physician, requested by resident or responsible person or when determined by the facility that additional level of care is needed. An additional charge will be assessed by Facility when overnight wake staff is provided.” Interviews conducted revealed the following: 3 of 3 staff confirm all residents have a operating call system to which residents can push when needing assistance. Staff interviews stated they respond to the resident call system. Two of two staff stated that during the middle of the night when they go to the bathroom, they conduct resident rounds. 4 of 4 residents confirmed that the facility has staff always present and are never left unattended inside the facility. All four residents interviewed indicated that staff try their best to provide good care.
It is alleged that the facility did not ensure that residents’ falls were reported to the Department. Department file review revealed that R1 had a fall on June 8, 2024, and it was reported to the Department on June 11, 2024. Interview with the Administrator revealed that R1 only had one fall since their admissions date of March 1, 2023, and the one falls was reported to the Department within the seven day regulation requirements. Incidents are always reported by a telephone call to the LPA followed by LIC624 submission. R1 only had another incident where their arm was caught in between the railing of their bed but was no injuries or falls associated to that incident.

Based on the information gathered during the investigation, interviews and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

This report was reviewed with Administrator and a copy was furnished to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2