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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202269
Report Date: 03/09/2022
Date Signed: 03/09/2022 04:02:55 PM

Document Has Been Signed on 03/09/2022 04:02 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:EVERGREEN GUEST HOME #1FACILITY NUMBER:
435202269
ADMINISTRATOR:EVELYN CANONIZADOFACILITY TYPE:
735
ADDRESS:3127 HAGA DR.TELEPHONE:
(408) 440-2887
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 5DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Marina GumaradTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Marina Gumarad.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen and dining area, living room area, hallways, three out of three resident bedrooms, garage, and hallways. LPA Marrufo observed the visitor screening area. LPA Marrufo observed a 3-day supply of perishable food supplies and a 7-day supply of non-perishable foods. LPA Marrufo observed a PPE supply of at least 30 days.

LPA Marrufo toured the outside area and observed the exits to be clear of obstructions.

No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with staff Marina Gumarad and over telephone with Administrator Marina Gumarand and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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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