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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201385
Report Date: 10/24/2023
Date Signed: 10/24/2023 10:50:00 AM

Document Has Been Signed on 10/24/2023 10:50 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 DEVELOPMENT CENTERFACILITY NUMBER:
435201385
ADMINISTRATOR:CAROLINE C. MAYOFACILITY TYPE:
775
ADDRESS:2887 MCLAUGHLIN AVENUE,BLDG. ATELEPHONE:
(408) 578-1280
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 216CENSUS: 80DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Administrator Caroline C MayoTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Caroline C Mayo . ADM informed LPA that the facility has 40 staff and approximately 80 clients.

LPA toured the facility inside out with ADM which included; the classrooms, kitchen, conference rooms, office areas, and restrooms. The staff area of the facility was also inspected. Front yard and backyard of the facility was also inspected. There was no obstruction to block the walkways. LPA observed various clients doing activities during visit. Some of the activities included dancing, drawing, working on puzzles. LPA also observed some resident preparing to leave for an outing as well.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. Room temperature was at 75 degree F, and hot water temperature was measured to range from 108-110 degrees F in 4 client bathrooms.

The facility was equipped with smoke & carbon monoxide detectors, Fire extinguishers and they were last serviced on July 10, 2023. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 18, 2023.

LPA reviewed facility records for 3 staff and 3 clients. LPA reviewed 3 clients medications and centrally stored medication records.

No deficiencies cited during today's visit. This report was reviewed with Administrator Caroline C Mayo and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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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