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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202269
Report Date: 01/17/2024
Date Signed: 01/17/2024 04:36:19 PM

Document Has Been Signed on 01/17/2024 04:36 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 #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:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Marina GomaradTIME 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 Gomarad.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen area. LPA Marrufo observed a locked drawer for medications. LPA Marrufo observed a first aid kit that was complete. LPA Marrufo observed the food supplies in the kitchen and garage and observed there to be a perishable food supply of two days and a non-perishable food supply of at least seven days.

LPA Marrufo toured three out of three resident bedrooms and found them to have adequate bedding, furniture, and working lights. LPA Marrufo observed the facility bathroom had water temperature at 110 F.

LPA Marrufo observed the outdoor exits were clear of obstructions.

LPA Marrufo reviewed the facility Personal and Incidental Money Records Log and found all accounts to be balanced. LPA Marrufo reviewed Resident Records and Staff Records and found them to be complete. LPA reviewed the Emergency Disaster Drill Log and observed the last emergency drill occurred on 12/28/2023.

LPA Marrufo tested the facility smoke detectors and found 2 out of 4 smoke detectors were not functioning properly when tested and there was no smoke detector in the facility hallway. LPA Marrufo did not observe a carbon monoxide detector during visit and staff were unable to find an installed carbon monoxide detector during visit.

A deficiency was cited as per California Code of Regulations Title 22. An LIC9102 Advisory Note was issued. This report was reviewed with Marina Gomarad and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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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Document Has Been Signed on 01/17/2024 04:36 PM - It Cannot Be Edited


Created By: David Marrufo On 01/17/2024 at 04:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EVERGREEN GUEST HOME #1
FACILITY NUMBER: 435202269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having any carbon monoxide detectors in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2024
Plan of Correction
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Licensee agrees to install at least one carbon monoxide detector in the facility and send photographic evidence to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
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