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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425140
Report Date: 04/10/2025
Date Signed: 04/10/2025 04:28:08 PM

Document Has Been Signed on 04/10/2025 04:28 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
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:
04/10/2025
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Regina Abdelghani, Lead Caregiver TIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George made an announced to the facility to conduct a 1 year required visit. LPA was greeted and granted entry and with Regina Abdelghani, Lead Caregiver. The home continues to not have any residents in care, and it has been this way since 2016. Per Regina the plan is to meet with the Administrator once she returns back to the Country, to see what the plan will be moving forward. LPA verified contact information for the facility and will update the facility phone number as needed.

LPA conducted a tour of the interior and exterior areas of the facility. The facility was observed to be be clean, and clutter free with all exits being clear from any obstructions. The sharps, chemicals and other hazardous items were observed to be locked. There are no pools of bodies of water on the premises, as well as no known guns or ammunition. The facility was observed to have (1) smoke detector with a battery inside that was operable. LPA did not observe any carbon monoxide detectors, deficiency cited, $500 immediate civil penalties are being assessed. The facility has (2) fire extinguishers that are fully charged and last serviced on 05/10/24. The hot water temperature was tested and measured to be 113.8 degrees Fahrenheit.

A facility file review was conducted on 4/2/25, and the facility annual fees were observed to not have been paid. During today's visit LPA followed up and was informed by Regina that the payment was mailed off on Tuesday 04/08/25. LPA reviewed staff files for staff present and observed for staff to possess valid CPR certification, and to have the other required training/CEUs that were completed through approved vendors.

The facility was observed to be insufficient food supply, however there are no residents in care, LPA discussed the requirement of a 2 day supply of perishable and a 7 day supply of non perishable food items should be purchased prior to accepting any residents in the home.
NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EVERGREEN CHATEAU
FACILITY NUMBER: 336425140
VISIT DATE: 04/10/2025
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LPA observed for bedroom #2 and bedroom #3 to not have beds inside the room, however there was the other required furniture, such as lamp, and chest of drawers. Per Regina the new beds can be purchased or the resident can bring their own bed it depends on what they prefer.

The facility was observed to not have the required postings: such as the PUB475, personal rights, and Long Term Care Ombudsman, facility sketch. The emergency disaster plan is reported locked inside the staff office and was unavailable for review during today's visit. LPA discussed that the facility is to submit proof of the required postings at the facility no later than 5pm Monday 04/24/25. There was no proof of valid aliability insurance, deficiency cited.

Based on today's inspection a citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted where a copy of this report, 809D, LIC421IM appeal rights, LIC9098-Proof of Corrections form, glossary and LIC811-Confidential names list was reviewed and provided to Regina Abdelghani, Lead Caregiver.
NAME OF LICENSING PROGRAM MANAGER: Tricia Danielson
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 04/10/2025 04:28 PM - It Cannot Be Edited


Created By: Javina George On 04/10/2025 at 03:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EVERGREEN CHATEAU
FACILITY NUMBER: 336425140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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The Licensee agrees to purchase and install at minimum of one (1) carbon monoxide detector. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tricia Danielson
NAME OF LICENSING PROGRAM MANAGER:
Javina George
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/10/2025 04:28 PM - It Cannot Be Edited


Created By: Javina George On 04/10/2025 at 03:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EVERGREEN CHATEAU
FACILITY NUMBER: 336425140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 times which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2025
Plan of Correction
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The Licensee agrees to submit proof of valid liability insurance. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tricia Danielson
NAME OF LICENSING PROGRAM MANAGER:
Javina George
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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