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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200459
Report Date: 12/26/2024
Date Signed: 12/26/2024 12:59:24 PM

Document Has Been Signed on 12/26/2024 12:59 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/
DIRECTOR:		OSUKA, ADA P.FACILITY TYPE:
735
ADDRESS:2292 N. LIVERMORE AVENUETELEPHONE:
(925) 487-1551
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 5CENSUS: 3DATE:
12/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Ada Osuka, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On 12/26/2024 at 9:20AM, 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. LPA was informed that one client was present at the facility and the other two clients were at day program.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 1/18/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 106.5 degrees F in the hallway bathroom. There were adequate lighting in each room. First Aid kit is complete. Last fire drill was conducted on 12/10/2024.

LPA reviewed 3 clients and 3 staff files starting at 10:00AM. LPA observed clients and staff files were complete. LPA reviewed client's P&I money with log and did not observe discrepancies. LPA reviewed the three client's medications with MAR (Medication Administration Record) during inspection.

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: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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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