Evergreen Adult Home Care at Tustin

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual. LPA was greeted and granted entry by staff and explained the reason for the visit. The facility is a two-story home. The first floor houses three shared resident bedrooms, two bathrooms, living room, family room, dining room, kitchen, game room, staff room, covered patio, backyard and 2-car garage. The second floor houses the management office, three staff rooms, one bathroom and loft. The second floor is inaccessible to residents. The facility is licensed for six non-ambulatory residents with an approved hospice waiver for six. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and testing hot water temperature in two of two resident bathrooms. The hot water temperature measured between 111 and 111.5 degrees Fahrenheit. The facility’s last emergency drill was conducted on April 18, 2026. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. LPA reviewed two out of two staff training and fingerprint records. LPA conducted a complete review of five out of five resident records LPA confirmed that administrator has a current certificate which expires on September 15th, 2026. Based on observations made during today's visit no deficiencies noted. An exit interview was conducted and a copy of this report was providedthe state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to the facility today to conduct a required annual visit. LPA was greeted and granted entry and explained the reason for the visit. Administrator arrived shortly after The facility is a two-story home. The first floor houses three shared resident bedrooms, two bathrooms, living room, family room, dining room, kitchen, game room, staff room, covered patio, backyard and 2-car garage. The second floor houses the management office, three staff rooms, one bathroom and loft. The second floor is inaccessible to residents. The facility is licensed for six non-ambulatory residents with an approved hospice waiver for six. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and testing hot water temperature in two of two resident bathrooms. The hot water temperature measured between 109 and 115 degrees Fahrenheit. The facility’s last emergency drill was conducted on June 5th 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. LPA reviewed two out of two staff training and fingerprint records. LPA conducted a complete review of resident records LPA confirmed that administrator has a current certificate which expires on September 15th, 2026. Based on observations made during today's visit no deficiencies noted. An exit interview was conducted and a copy of this report was providedthe state’s words, verbatim · CDSS document, Jun 26, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived and was greeted and granted entry by Administrator/Licensee Tamanna Rahman and Manager Designee Tawsique Salam. Assistant Administrator Latif Rahman and Manager of Facility Affairs Alexis Deseo were also present during inspection. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by Community Care Licensing (CCL) on 1/26/2024. The facility is a two-story home. The first floor houses three shared resident bedrooms, two bathrooms, living room, family room, dining room, kitchen, music room, staff room, covered patio, backyard and 2-car garage. The second floor houses the management office, three staff rooms, one bathroom and loft. The second floor is inaccessible to residents. Resident Bedrooms have all the necessary requirements including bed, chair, storage for clothing and ample lighting. LPA observed all windows were screened. All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 112.4 degrees Fahrenheit and 113.9 degrees Fahrenheit in the Resident bathrooms. LPA observed the fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. Medication and First-Aid Kit will be locked in a cabinet in the dining room. Resident & Staff Files will be locked in the management office on the second floor. The fire clearance was approved by a fire inspector of Orange County Fire Authority on 3/12/2024. LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and are stored and locked in cabinets in the garage. A supply of extra linens is stored in a closet in the hallway as well as the garage Emergency Phone Numbers, Exit Plan, Activity Calendar and Menu are all posted and available for review. LPA observed other necessary postings in the living room and dining room. Smoke and Carbon Monoxide detectors are stationed throughout the home and are wired together. Both types of detectors were tested and noted as operational. Operational appliances include a gas stove, oven, two refrigerators, freezer, dishwasher, microwave, washing machine and dryer. LPA provided the Component III presentation to offer information and resources regarding maintaining facility compliance. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.the state’s words, verbatim · CDSS document, May 31, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Rahman, Tamanna & Salam, Tawsique - Administrator/Applicant Interview Method: Telephone interview On 04/25/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Apr 25, 2024