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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200459
Report Date: 01/17/2024
Date Signed: 01/17/2024 12:49:37 PM

Document Has Been Signed on 01/17/2024 12:49 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 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:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ada Osuka, AdministratorTIME COMPLETED:
01:05 PM
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On 1/17/2024 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Ada Osuka and explained the purpose of the visit. The facility’s fire clearance was approved for 5 clients of which 1 maybe non-ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, and outdoor area. Smoke and carbon monoxide combination detectors were observed in operating condition. Fire extinguisher was observed to be full. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 115.4 degrees F in the hallway bathroom. There were adequate lighting in each room. First Aid kit is complete. Last fire drill was conducted on 1/1/2024.

LPA reviewed 3 clients and 3 staff files starting at 10:15AM. LPA interviewed 2 clients and 2 staff at 10:55AM. LPA reviewed a sample of client's medications starting at 12:15PM.

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: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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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