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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201385
Report Date: 10/07/2022
Date Signed: 10/07/2022 03:14:55 PM

Document Has Been Signed on 10/07/2022 03:14 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
CENTRAL COAST CR/RES, 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: 60DATE:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Caroline MayoTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection focusing on infection control. LPA met with Administrator, Caroline Mayo.

During visit, LPA toured the facility to include the activity rooms, office, bathrooms, kitchen, and exterior. All fire exit routes were free and clear of obstruction.

Facility has a designated central entry point for symptom screening and temperature check for all visitors, clients, and staff. Hand sanitizer made available at entry and throughout the facility. Bathrooms supplied with hand washing sign, paper supplies, and hygiene products. Facility clean and disinfect multiple times daily and as needed. The facility has an isolation room to include a lidded trash can and Personal Protective Equipment (PPE) supplies. LPA reviewed the facility's procedures to isolation and infection control training. The following posters observed to include social distancing, required mask, and symptoms of COVID.

During visit, the following documents were obtained to include facility's change of Administrator and staff's LIC-9182.

No deficiencies were cited per California Code of Regulation, Title 22. Advisory note provided.

This report was reviewed with Administrator, Caroline Mayo and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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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