435202601-8-23-2024-26-AS-MPAA-D8EUXM-20240823155834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202601
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:59:15 PM

Document Has Been Signed on 08/23/2024 03:59 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 RESIDENTIAL CARE HOME INC		FACILITY NUMBER:	435202601
ADMINISTRATOR:	DEVANO, DANTE		FACILITY TYPE:	740
ADDRESS:	5707 FLOWERING MEADOW COURT		TELEPHONE:	(408) 300-1054
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	6	CENSUS: 6	DATE:	08/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Dante Devano & Belinda Devano		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	8/23/2024 at 1:20 p.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required 1 year inspection. LPA was greeted by 2 staff and LIC/ADM arrived 10 minutes after LPAs arrival. LPA met with licensees/administrators (LIC/ADMs) Dante Devano & Belinda Devano. LPA stated the purpose of the visit. The facility serves adults 60 ad over, approved for 5 non-ambulatory, of which 2 may be bedridden. Bedridden to reside at room #3 and #6 only and hospice waiver for 5. At 1:30 p.m. LPA with ADMs toured the facility inside and outside including the resident's bedrooms, bathroom, kitchen, garage, dining room, living room, exterior perimeter and backyard. Bedrooms and bathrooms were observed to be organized and sanitary. Bedrooms has sufficient storage for resident's personal belongings. 3 of 6 resident bedroom are equipped for hospice care. 3 of 3 Bathrooms inspected are equipped with grab bars and nonskid floor mats, sanitary and organized. The kitchen, dining and living room are kept organized, sanitary and free from debris. No sharps, knives and chemicals are kept in the kitchen. Knives and sharps are in a locked cabinet. LPA observed 2 days worth of perishables and 7 days worth of nonperishable food. The kitchen sink hot water measured with the digital thermometer at 124.9 degree F and witnessed by LIC/ADM. LPA advised ADM for taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. LIC/ADM have created the warning sign for the kitchen sink and prominently displayed the sign during the time of inspection. Hallways and passage way from kitchen, living room, emergency exit doors are free from obstruction. Facility temperature is maintained at 78 degrees F. Hot water temperature was measured in the 2 bathrooms with a digital thermometer witnessed by the LIC/ADM at 110.7 degree F to 110.9 degree F. page 1 of 2

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

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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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: EVERGREEN RESIDENTIAL CARE HOME INC	FACILITY NUMBER: 435202601
	VISIT DATE: 08/23/2024

NARRATIVE

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Facility is equipped with comfortable lighting. The first aid cabinet is located in the dining room, can be easily accessed by staff with the first aid manual. Resident's medication are in a locked cabinet, accessible only to staff who are trained and authorized to administer medicines.

LPA observed a laundry room that is kept organized and free from laundry supplies. The laundry room is connected to the garage which was kept organized and free from debris and obstruction.

LPA observed a pool surrounded by a fence that is locked and not accessible to residents. The pool is maintained and ready for use at any time by residents with supervision only. The shed storage is locked and not accessible to residents.

Fire and earthquake drill was conducted on 1/6/24, 4/6/24 and 7/6/24. Fire extinguisher was last inspected on 6/4/2024. The facility is equipped with a wall fire alarm system that notifies the fire department.
The facility is equipped with carbon monoxide and smoke alarm system that are in good working condition.

LPA reviewed 3 of 6 residents and 4 of 9 staff records. Facility staff have criminal record clearance to work at the facility and associated to the facility. Facility staff have annual required training and current first aid certificates. Residents centrally stored medication record and destruction (CSMDR) are current and up to date.

No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Licensees/Administrators Dante Devano & Belinda Devano and a copy of this report provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC809 (FAS) - (06/04)

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