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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202601
Report Date: 07/21/2021
Date Signed: 07/21/2021 05:20:15 PM

Document Has Been Signed on 07/21/2021 05:20 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:EVERGREEN RESIDENTIAL CARE HOME INCFACILITY NUMBER:
435202601
ADMINISTRATOR:DEVANO, DANTEFACILITY TYPE:
740
ADDRESS:5707 FLOWERING MEADOW COURTTELEPHONE:
(408) 300-1054
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 6CENSUS: 5DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Belinda DevanoTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Administrator Belinda Devano.

At 11:06 AM, LPA entered the facility through the facility's central entry point and was screened by staff. At 11:12 AM, a tour of the facility was conducted. COVID-19 postings were observed throughout the facility. Residents' bedrooms were inspected. Residents were observed in their individual bedrooms. Lunch was observed served in the dining room and in residents' bedrooms. Facility room temperature was 79 F degrees during inspection.

Hand sanitizers, soap, and paper supplies were observed available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food supply was observed in the premises. Personal protective equipment (PPE) and disinfection supplies were available in the premises.

Per Administrator, all residents and staff are fully vaccinated against COVID-19. The facility is currently accepting visitors inside the facility and also has a designated indoor and outdoor visitation area. The facility's COVID-19 mitigation plan has been reviewed by the Department.

Exit routes were observed clear and unobstructed. The facility is equipped with smoke detectors, fire extinguishers, and a carbon monoxide detector. Swimming pool was enclosed with a locked perimeter fencing.

No deficiencies were cited. Exit interview conducted with Belinda Devano and a copy of this report was provided during visit.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Gladys Kuizon
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2021
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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