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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200918
Report Date: 11/28/2022
Date Signed: 11/28/2022 04:48:30 PM


Document Has Been Signed on 11/28/2022 04:48 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:EVCO CAREFACILITY NUMBER:
435200918
ADMINISTRATOR:MICHELLE BAYQUENFACILITY TYPE:
740
ADDRESS:3274 EVCO COURTTELEPHONE:
(408) 937-1625
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 4DATE:
11/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Michelle Bayquen, ADMTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Michelle Bayquen. COVID posters were observed at main entrance.

LPA toured the facility inside out with ADM. Dinning room, kitchen and family room were inspected. 4 resident bedrooms and 2 restrooms were inspected. Not all trash cans are with covers, ADM stated the facility will fix this issue in 3 days. No posters of washing hands for 20 seconds were observed by the sink in kitchen and restrooms. ADM stated the facility will put the posters of washing hands for 20 seconds in 3 days. 3 residents were observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked.

Fire extinguisher was serviced on 10/2/2022. The facility was equipped with smoke and carbon monoxide detectors. Front yard and backyard were inspected. There was no obstruction to block the walkways. ADM stated all the residents and staff are fully vaccinated with Pfizer.

No citation were noted today. Exit interview was conducted with ADM This report was provided to ADM for signature. A copy of this report was provided to ADM
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
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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