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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200459
Report Date: 01/06/2022
Date Signed: 01/06/2022 10:22:53 AM

Document Has Been Signed on 01/06/2022 10:22 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 RESIDENTIAL CAREFACILITY NUMBER:
019200459
ADMINISTRATOR:OSUKA, ADA P.FACILITY TYPE:
735
ADDRESS:2292 N. LIVERMORE AVENUETELEPHONE:
(925) 487-1551
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 5CENSUS: 3DATE:
01/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Ada Osuka, AdministratorTIME COMPLETED:
10:35 AM
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On 1/6/2022 at 8:53AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with staff, Oluchi Iheriohamma and explained the purpose of the visit. Administrator, Ada Osuka arrived 30 minutes later.

Upon entry, staff did not screen LPA prior to entry. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, living room, and outdoor areas. LPA observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPA observed temperature logs for clients and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPEs, food, and paper supplies were sufficient.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2022
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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