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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707892
Report Date: 04/26/2023
Date Signed: 04/26/2023 11:17:52 AM

Document Has Been Signed on 04/26/2023 11:17 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EVERGREEN ADULT RESIDENTIAL CAREFACILITY NUMBER:
430707892
ADMINISTRATOR:DUMO, VIOLETAFACILITY TYPE:
735
ADDRESS:3621 ROX PLACE COURTTELEPHONE:
(408) 238-6129
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 5DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Licensee, Violeta DumoTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) Simi Rai and Manuel Monter conducted an unannounced annual inspection visit and met with Licensee Violeta Dumo.

During visit, LPAs toured the inside and outside of the facility. The facility has a structure at the backyard that is not being used as a living space and LPAs observed the space is being used for storage. LPAs toured the facility kitchen and observed at least 2 days of perishable food supply of at least 7 days of nonperishable food supply. Sharps and medications were locked in secured areas. There was a first aid kit in the facility. LPAs observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

The facility bathroom had available soap, paper towels, and trash cans with lids. The showers had grab bars, non-skid mats, and shower chairs. The water temperature in the bathroom sinks ranged from 115.96F - 116F. The water temperature in the kitchen sink was 115.9F. Fire extinguisher were observed and were inspected on May 2022.

Facility smoke and carbon monoxide detectors were tested and found to be in functioning condition. Three out of three resident bedrooms had available bedding, drawers, and functioning lights. LPAs reviewed facility records for four staff and three residents. LPAs reviewed resident medications and central stored medication records. LPAs interviewed 2 staff and 1 resident.

Technical Violation were issued. See LIC9102 pages for more information.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with Licensee Violeta Dumo. A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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