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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202392
Report Date: 02/13/2023
Date Signed: 02/13/2023 04:57:34 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/13/2023 04:57 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:EVONNE'S RESIDENTIAL CARE HOME #1FACILITY NUMBER:
435202392
ADMINISTRATOR:PHILOMENA AGBONTAENFACILITY TYPE:
740
ADDRESS:2719 PENITENCIA CREEK RD.TELEPHONE:
(408) 661-5746
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:6CENSUS: 5DATE:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Philomena AgbontaenTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with Administrator (ADM) Philomena Agbontaen. Upon arrival, ADM took LPA body temperature and checked LPA into the guest book. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. 2 staff and 5 residents were observed in facility.

LPA toured the facility inside out with ADM. LPA inspected living room, family room, kitchen, dinning area, and laundry room. Medication closet, knives closet were observed locked. The cleaning product cabinet under the sink in kitchen was observed unlocked. ADM stated the facility will put it on lock within 5 days. There are 4 rooms for residents, and one staff live-in room in facility. 3 bathrooms are in facility. Paper towels were observed with holders, Some trash cans were observed without covers. ADM stated the facility will replace all the trash cans with covers within 5 days. Posters of washing hands for 20 seconds were not observed in kitchen even though there were posters of washing hands by the sinks in kitchen and restrooms. ADM stated the facility will put the posters of washing hands for 20 seconds in the kitchen and restrooms within 5 days. Cloth towels were observed in kitchen. Room temperature was observed at 70 degree F, and hot water temperature was observed at 105 degree F. 2 days perishable food supplies and 7 days non perishable food supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. ADM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 03/15/2022. LPA inspected the backyard, there was no obstruction to block the walkway. ADM stated all staff and residents are fully vaccinated and done with booster.

No citation noted during inspection. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
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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