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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202269
Report Date:
01/25/2023
Date Signed:
01/25/2023 04:42:25 PM
Document Has Been Signed on
01/25/2023 04:42 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 GUEST HOME #1
FACILITY NUMBER:
435202269
ADMINISTRATOR:
EVELYN CANONIZADO
FACILITY TYPE:
735
ADDRESS:
3127 HAGA DR.
TELEPHONE:
(408) 440-2887
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95111
CAPACITY:
6
CENSUS:
6
DATE:
01/25/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
03:45 PM
MET WITH:
Marina Gumarad
TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Marina Gumarad.
LPA Marrufo toured the facility inside and out. LPA Marrufo observed there to be a visitor screening form. LPA Marrufo observed a 30-day supply of PPEs. LPA Marrufo observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. LPA Marrufo observed there to be available soap and paper towels in the bathroom.
LPA Marrufo toured the outdoor exits and observed them to be free of obstructions.
No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Marina Gumarad.
SUPERVISORS NAME
:
Sarah Yip
LICENSING EVALUATOR NAME
:
David Marrufo
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/25/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/25/2023
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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