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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011405820
Report Date: 11/20/2023
Date Signed: 11/20/2023 01:01:28 PM

Document Has Been Signed on 11/20/2023 01:01 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:EVERGREEN PROGRAMFACILITY NUMBER:
011405820
ADMINISTRATOR:LOPEZ, VERONICAFACILITY TYPE:
775
ADDRESS:797 MONTAGUE AVENUETELEPHONE:
(510) 895-2838
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 150CENSUS: 35DATE:
11/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Veronica Lopez, AdministratorTIME COMPLETED:
01:10 PM
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On 11/20/23 Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator Veronica Lopez and explained the purpose of the visit. Day program operates from 8:00 a.m. to 3:00 p.m. Monday to Friday. There were 6 staff observed working at the program today.

LPA toured facility including but not limited to: activity rooms, kitchen, bathrooms, office space, and the outside recreational area. Clients bring their own lunches and snacks are provided by the program. The hot water temperature in men's bathroom measured 118.8 degrees Fahrenheit. Cleaning supplies are locked in the kitchen and are inaccessible to clients. Medications are not handled/dispensed by this program. There are no bodies of water or fire safety hazards observed. Restrooms are maintained in safe and in sanitary operating condition. The program has 4 vans used for client outings and transportation. LPA reviewed 5 client and 5 staff files. Emergency disaster drills are conducted quarterly. Fire extinguishers throughout facility were last inspected 11/21/23. First aid kit was checked and observed to be complete.

No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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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