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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011405820
Report Date: 10/21/2024
Date Signed: 10/21/2024 03:57:20 PM

Document Has Been Signed on 10/21/2024 03:57 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:EVERGREEN PROGRAMFACILITY NUMBER:
011405820
ADMINISTRATOR/
DIRECTOR:		LOPEZ, VERONICAFACILITY TYPE:
775
ADDRESS:797 MONTAGUE AVENUETELEPHONE:
(510) 895-2838
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 150CENSUS: 56DATE:
10/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Veronica Lopez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 10/21/2024 at 1:00 PM, Licensing Program Analysts (LPAs) D. Doidge and J. Sampair arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPAs stated the purpose of the visit to Veronica Lopez, Administrator.

The LPAs 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.

LPAs reviewed 6 client and 5 staff files. Emergency disaster drills are conducted quarterly. Fire extinguishers throughout facility were last inspected 11/21/2022. First aid kit was checked and observed to be complete.

One B-Type deficiency was cited during this inspection (refer to LIC 809-D for additional information).

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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Document Has Been Signed on 10/21/2024 03:57 PM - It Cannot Be Edited


Created By: David Doidge On 10/21/2024 at 03:43 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: EVERGREEN PROGRAM
FACILITY NUMBER: 011405820

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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, as fire extinguishers were not serviced within 1 year, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2024
Plan of Correction
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Facility to have fire extinguishers serviced or replaced and submit proof to LPA D. Doidge by POC date
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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:David Doidge
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


LIC809 (FAS) - (06/04)
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