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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202269
Report Date: 01/22/2025
Date Signed: 01/22/2025 04:16:44 PM

Document Has Been Signed on 01/22/2025 04:16 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/
DIRECTOR:
EVELYN CANONIZADOFACILITY TYPE:
735
ADDRESS:3127 HAGA DR.TELEPHONE:
(408) 440-2887
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 3DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Daisy FernandezTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with staff Daisy Fernandez.

During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be a locked storage area for medications. LPA observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days in the kitchen and garage pantry areas. LPA reviewed the first aid kit and found it to be complete.

LPA toured three out of three resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA tested the smoke detectors/carbon monoxide detectors in three out of three resident rooms, the hallway, and the living room area, and all smoke detectors/carbon monoxide detectors functioned properly when tested.

LPA toured one out of one resident bathroom. The bathroom had working lights and available soap and paper towels. The water temperature in the bathroom measured at 110 F.

LPA reviewed the Personal and Incidental Money Log and the Centrally Stored Medication Log for 3 out of 3 residents. Both logs were balanced and complete during review.

Due to time constraints, this annual inspection will need to be completed at a later date.

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

This report was reviewed with Daisy Fernandez and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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