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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201385
Report Date: 08/16/2024
Date Signed: 08/16/2024 12:17:33 PM

Document Has Been Signed on 08/16/2024 12:17 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/
DIRECTOR:
CAROLINE C. MAYOFACILITY TYPE:
775
ADDRESS:2887 MCLAUGHLIN AVENUE,BLDG. ATELEPHONE:
(408) 578-1280
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 216CENSUS: 69DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Administrator Caroline MayoTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Manuel Monter and Santino Fortes conducted an unannounced annual inspection visit, and met with Administrator (ADM) Caroline C Mayo . ADM informed LPA that the facility has 39 staff and 69 clients.

LPAs toured the facility inside out with S1 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 eating in the courtyard.

S1 stated the facility does not provide meals. 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 76 degree F, and hot water temperature was measured to range from 112 degrees F in 4 client bathrooms.

The facility was equipped with smoke & carbon monoxide detectors, Fire extinguishers and they were last serviced on June 6, 2024. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on June 30, 2024.

LPA reviewed facility records for 3 staff and 3 clients. LPA reviewed 3 clients medications and centrally stored medication records. LPA interviewed 2 clients and 2 staff.

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: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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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