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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202601
Report Date: 08/22/2022
Date Signed: 08/22/2022 10:11:54 AM


Document Has Been Signed on 08/22/2022 10:11 AM - 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 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:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Belinda DevanoTIME COMPLETED:
10:30 AM
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On 08/22/2022, Licensing Program Analyst Mandeep Kaur (LPA) conducted an unannounced annual inspection. LPA met with Licensee Belinda Devano.

Facility observed to have designated entry point. Upon Entrance, LPA temperature and screening was done.

LPA toured the facility, including living room, kitchen, dining room, laundry room, resident bedrooms, bathrooms, and back yard. All staff members observed to be wearing masks.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. All cleaning supplies and chemicals noted to be in locked cabinets and closets. Smoke/carbon monoxide detectors were observed.
LPA observed at least 30 days supply of Personal Protective Equipment (PPE). Hand washing signs were observed throughout the facility and in the bathrooms.

No deficiency was cited as per California Code of Regulations Title 22. Advisory notes issued. This report was reviewed with Licensee Belinda Devano. A copy of the signed report and advisory notes were provided .
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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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