011405820-11-3-2022-15-AS-JCCR-CKTNW5-20221103104859

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 011405820
Report Date: 11/03/2022
Date Signed: 11/03/2022 10:49:37 AM

Document Has Been Signed on 11/03/2022 10:49 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	EVERGREEN PROGRAM		FACILITY NUMBER:	011405820
ADMINISTRATOR:	LOPEZ, VERONICA		FACILITY TYPE:	775
ADDRESS:	797 MONTAGUE AVENUE		TELEPHONE:	(510) 895-2838
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY: 150		CENSUS: 27	DATE:	11/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Veronica Lopez, Administrator		TIME COMPLETED:	10:58 AM

NARRATIVE

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On 11/3/2022 at 9:44 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Administrator Veronica Lopez and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, common areas, kitchen, and backyard. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. The facility has a mitigation plan. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks.

The following deficiency was observed during the visit:

At 10:10 LPA observed the fire extinguisher had not been serviced since 2019

The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided. Exit interview conducted.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

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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Document Has Been Signed on 11/03/2022 10:49 AM - It Cannot Be Edited

Created By: Jill Clancy-Czuleger On 11/03/2022 at 10:34 AM

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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: EVERGREEN PROGRAM	FACILITY NUMBER: 011405820
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82020

Fire Clearance

All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because their fire extinguisher has not been serviced since 2019 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2022
	Plan of Correction
1 2 3 4	The facility will have the extinguisher serviced. Proof of correction will be sent to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Harpreet Humpal

LICENSING EVALUATOR NAME:

Jill Clancy-Czuleger

LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

LIC809 (FAS) - (06/04)

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