435202663-1-19-2021-26-AS-GKUN-BXF2DE-20210119161812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202663
Report Date: 01/19/2021
Date Signed: 01/19/2021 04:18:21 PM

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 HOME LIVING		FACILITY NUMBER:	435202663
ADMINISTRATOR:	NGUYEN, THU NGOC		FACILITY TYPE:	740
ADDRESS:	3291 SYLVAN DR		TELEPHONE:	(408) 528-1017
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY:	6	CENSUS: 5	DATE:	01/19/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Thu Nguyen and Ian Sumbi		TIME COMPLETED:	03:00 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	Licensing Program Analyst (LPA) Gladys Kuizon conducted a Technical Assistance tele-visit today with CA Department of Public Health (CDPH) Health Facilities Evaluator Nurse (HFEN) Irene Thibault, RN. Present in the tele-visit were Administrator Thu Nguyen and lead staff, Ian Sumbi. At 1:13 PM, a facility tour was conducted. Staff were observed wearing full Personal Protective Equipment (PPE) including N-95 mask, face shield, isolation gown, and gloves. The facility has a central entrance where screening of staff and essentials visitors are conducting. Sufficient PPE, hand hygiene supplies, and disinfectants were available in the premises. The facility has a dedicated isolation room and a dedicated bathroom for resident(s) who are in isolation. Based on today's facility inspection, the following improvements are being recommended: 1. Facility shall have a written screening questionnaire listing up to date COVID-19 related symptoms. Facility was advised to obtain most current symptom list from the Centers for Disease Control (CDC)'s website. 2. Covered trash bins with foot pedal is recommended for use in the facility to minimize touching of surfaces. 3. Hand-washing guide posters shall be placed on all hand-washing stations. 4. HFEN recommends moving COVID-19 positive resident to a bedroom with its own bathroom, if possible. Continued, see LIC 809-C, page 2 of 2.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME LIVING	FACILITY NUMBER: 435202663
	VISIT DATE: 01/19/2021

NARRATIVE

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5. PPE donning and doffing station shall be made available outside the isolation room. PPE donning and doffing guide poster shall be placed by donning and doffing stations.

The following must be submitted by licensee to Community Care Licensing by January 24, 2021:

1. Record of PPE and COVID-19 infection control training for staff

2. LIC 500 - Personnel Schedule

3. Alternate Staffing Plan

This report was discussed with Administrator Thu Nguyen and Ian Sumbi and a copy provided via email for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys Kuizon	TELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2021

LIC809 (FAS) - (06/04)

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