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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202269
Report Date: 01/27/2025
Date Signed: 01/27/2025 03:35:24 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/27/2025 03:35 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: 4DATE:
01/27/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Tessie FernandezTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Annual Continuation Visit and met with Tessie Fernandez, staff.

The visit was a continuation of the annual visit that occurred on 01/22/2025.

During visit, LPA Marrufo reviewed the resident records for 4 out of 4 residents. All resident records were found to be complete. LPA reviewed 5 staff records and found them to be complete.

The Emergency Disaster Drill Log indicates that the last drill occurred on January 10th, 2025.

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

This report was reviewed with Tessie Fernandez and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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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