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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425140
Report Date: 05/06/2024
Date Signed: 05/06/2024 10:17:35 AM

Document Has Been Signed on 05/06/2024 10:17 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:EVERGREEN CHATEAUFACILITY NUMBER:
336425140
ADMINISTRATOR/
DIRECTOR:
MAHBOUBEH ARABSHAHIFACILITY TYPE:
740
ADDRESS:32913 NORTHSHIRE CIRCLETELEPHONE:
(951) 303-1051
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY: 6CENSUS: 0DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:House Manager Regina Abdelghani TIME VISIT/
INSPECTION COMPLETED:
10:28 AM
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Licensing Program Analyst (LPA) Sara Martinez arrived announced to conduct the required annual inspection. LPA was granted entry and met with House Manager Regina Abdelghani and stated the facility does not have clients at the home. The facility has not had any residents since 2016. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were in good repair and were present. The outdoor area was observed to be free of hazards. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Facility contains an updated Infection Control Plan and Emergency and Disaster plan. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Laundry room contained locked cabinets to store cleaning supplies, soap, and detergents. Centrally stored medication will be locked in a cabinet located in the laundry room. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. LPA reviewed staff file for one (1) staff and found staff have criminal record clearance, health screening with TB test, and updated training along with CPI and CPR/First Aid Certification.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Abdelghani.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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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