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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201385
Report Date: 10/07/2021
Date Signed: 10/13/2021 09:26:51 AM

Document Has Been Signed on 10/13/2021 09:26 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EVERGREEN ADULT DEVELOPMENT CENTERFACILITY NUMBER:
435201385
ADMINISTRATOR:DEANNA L. CORPUZFACILITY TYPE:
775
ADDRESS:2887 MCLAUGHLIN AVENUE,BLDG. ATELEPHONE:
(408) 578-1280
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 216CENSUS: 40DATE:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Caroline Mayo and Tiana Mayo MusikaTIME COMPLETED:
02:47 PM
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Licensing Program Analyst, Steve Nguyen, conducted an unannounced annual inspection with Administrator (AD), Caroline Mayo and Tiana Mayo.

LPA toured facility inside and out. LPA observed: Covid signs are present and in conspicuous vantage points, are exits are free of obstructions, emergency contact for residents were up to date, facility screening protocols will be enforce and staff will be retrained by AD, hand sanitizing station were available throughout facility, medicine cabinet were observed to be locked, paper towers are in use, and physical distancing was observed to be in practice.

No citation was issued at this time.

LPA went over report findings with Administrator, Caroline Mayo and Tiana Mayo, for review and a copy was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
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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