<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530251
Report Date: 01/07/2025
Date Signed: 01/07/2025 11:45:12 AM

Document Has Been Signed on 01/07/2025 11:45 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:EVERLASTING ASSISTED LIVINGFACILITY NUMBER:
335530251
ADMINISTRATOR/
DIRECTOR:		ARBOLEDA, CZARINA MAEFACILITY TYPE:
740
ADDRESS:29213 FERN PINETELEPHONE:
(951) 579-0794
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 6CENSUS: 0DATE:
01/07/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Applicant/Administrator Czarina Arboleda and Applicant Archie ArboledaTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/07/2025, at 09:00 AM, Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility for the purpose of a Prelicensing Visit. LPA Brown met with Applicant/Administrator Czarina Arboleda and Applicant Archie Arboleda. An initial application for license to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 05/20/2024 for a total capacity of six (6). Fire clearance was granted on 06/24/2024 for six (6) non-ambulatory residents. LPA Brown observed the following:

Structure:
Facility was a one (1) level house with four (4) bedrooms, two (2) resident/staff bathrooms, living room, dining area, laundry room and kitchen. There is an attached two (2) car garage.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control the entire house.
Bedrooms:
Each resident bedrooms accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke and carbon monoxide alarm.
Bathrooms:
The two (2) staff/resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. At 09:45 AM, LPA Brown tested the water temperature in the resident bathrooms. LPA verified water temperature was measured at 110.6 degrees Fahrenheit.
***CONTINUED ON LIC 809C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: EVERLASTING ASSISTED LIVING
FACILITY NUMBER: 335530251
VISIT DATE: 01/07/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
***CONTINUED FROM LIC 809***
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA Brown observed the stove to be operational. Refrigerator/freezer were in working condition. Applicant/Administrator Arboleda reported that they will have more than two (2) days supply of perishable foods and LPA Brown observed more than seven (7) days supply of non-perishable foods. There was adequate seating for meals for all residents. Laundry room with washer and dryer was also observed. Laundry detergents and cleaning supplies are stored in the garage in a locked cabinet.
Living/Family room:
There was a living/family room with adequate seating for all residents and a working TV.

Linens and Hygiene Supplies: An adequate supply of linens was stored in a cabinet in the laundry room.
Yards/Outside:
Patio furniture for outdoor seating observed. Gate on the right side of the facility. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted in the hallway. Ombudsman poster, Let-Us-No poster, Personal Rights, House Rules, Visitation Policy, Emergency Disaster Plan, Rights of Resident Councils, Rights of Family Councils were noted posted in a common area.
Dementia Care Plan:
Dementia Care Plan was observed and reviewed during the visit today, 01/07/2025.
General items:
One (1) fire extinguisher was charged and located in the hallway of the facility. Seven (7) dual smoke alarms and carbon monoxide detectors were tested and were observed to be in working order. Resident records will be stored in a locked cabinet. First Aid kit with required components and first aid book, and locked area for medication storage was observed. LPA Brown observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 951-579-1599.
***CONTINUED ON LIC809C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: EVERLASTING ASSISTED LIVING
FACILITY NUMBER: 335530251
VISIT DATE: 01/07/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
***CONTINUED FROM LIC 809C**
There is enough Emergency water supply observed and the required 72-hour emergency food supply was observed from the regular food supply. Component III was completed on this day as well. Additionally, LPA Brown observed facility to have required single entry point with Sign In/Sign Out Sheet for Visitors and Residents, upon entering the facility. LPA observed activities for the residents such as books and games and planned menu.

The facility was evaluated in accordance with the California Code of Regulation (CCR), Title 22 Division 6 Chapter 8 to ensure the health and safety of residents in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report, LIC809 was reviewed and provided to Administrator/Applicant Czarina Arboleda and Applicant Archie Arboleda.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3