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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202392
Report Date: 02/14/2025
Date Signed: 02/14/2025 04:40:33 PM

Document Has Been Signed on 02/14/2025 04:40 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:EVONNE'S RESIDENTIAL CARE HOME #1FACILITY NUMBER:
435202392
ADMINISTRATOR/
DIRECTOR:		PHILOMENA AGBONTAENFACILITY TYPE:
740
ADDRESS:2719 PENITENCIA CREEK RD.TELEPHONE:
(408) 661-5746
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 7TOTAL ENROLLED CHILDREN: 0CENSUS: 7DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Evonne Evien, Designated AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Evonne Evien, Designated Administrator. LPA announced the purpose of the visit. LPA observed 6 resident and 2 staff.

During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature was measured at 43 degrees F and freezer temperature measured at 1 degrees F.

LPA toured 6 residents bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 111-113 degrees F.

LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 03/13/2023. LPA reviewed Fire and Earthquake log last disaster drill was conducted on 11/12/2024. ADM tested the smoke detectors in the hallway and found the smoke detector to function properly when tested.

LPA reviewed 3 resident records and 3 staff records. LPA observed 3 staff records to be incomplete missing required documents. ADM reviewed 3 resident Centrally Stored Medication.

Deficiency was cited as per California Code of Regulations Title 22. This report was reviewed with Designated Administrator Evonne Evien and a copy of this report and appeal rights were provided.
Romeo ManzanoTELEPHONE: (650) 388-2297
Marcela YanezTELEPHONE: (279) 789-1062
DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/14/2025 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: EVONNE'S RESIDENTIAL CARE HOME #1
FACILITY NUMBER: 435202392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above by not having complete staff files missing required documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Designated Administrator stated they will submit a letter of understanding regarding regulation and will submit by POC date 02/21/25 via email to LPA.
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.
Romeo ManzanoTELEPHONE: (650) 388-2297
Marcela YanezTELEPHONE: (279) 789-1062

DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025

LIC809 (FAS) - (06/04)
Page: 2 of 2