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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200712
Report Date: 06/21/2021
Date Signed: 06/21/2021 03:16:21 PM

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 SENIOR ASSISTED LIVINGFACILITY NUMBER:
019200712
ADMINISTRATOR:GARCIA, EMILYFACILITY TYPE:
740
ADDRESS:1710 MT DIABLO WAYTELEPHONE:
(925) 989-3345
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:6CENSUS: 6DATE:
06/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Janelle Garcia, AdministratorTIME COMPLETED:
03:25 PM
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On 6/21/2021 at 1:02PM, Licensing Program Analysts (LPAs) G. Luk and C. Lin arrived unannounced to conduct an Infection Control Inspection. LPAs met with staff, Mayumi Maniago and explained the purpose of the visit. Administrator, Janelle Garcia arrived 30 minutes later.

Upon entry, LPAs' temperature were checked, and LPAs observed hand sanitizer and hand washing sign at screening station. LPAs toured facility including but not limited to bedrooms, bathrooms, common areas, kitchen, and outdoor area. LPAs observed COVID-19 symptoms and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations.

During record review, LPAs observed visitors log and temperature log for residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed food and paper supplies were sufficient.

Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
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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