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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202663
Report Date: 06/29/2021
Date Signed: 07/01/2021 09:35:36 AM

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 LIVINGFACILITY NUMBER:
435202663
ADMINISTRATOR:KUMAR, SASHIFACILITY TYPE:
740
ADDRESS:3291 SYLVAN DRTELEPHONE:
(408) 459-7888
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY:6CENSUS: 4DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Sashi KumarTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Karen Taku conducted an unannounced Infection Control site visit. LPA met with Administrator (ADM) Sashi Kumar.

LPA toured the facility inside and out. COVIID-19 screening station and CDC screening questionnaire were observed in the entrance hallway of the facility. Screening station observed adequately stocked with PPE. Hand sanitizer is available to residents, staff and visitors. All staff were observed wearing masks. Bathrooms observed with hand washing posters and hygiene products. Bedrooms, kitchen, dining room, living room, and backyard were observed free obstruction and in good repair. Medication and sharp objects were observed in locked cabinets and inaccessible to residents in care.

LPA reviewed the facility’s COVID-19 Mitigation Plan.

LPA requested an updated copy of the following documents:

1. LIC 500- Personnel Summary
2. LIC 308- Designation of Administrative Responsibility
3. LIC 400- Affidavit Regarding Client/Resident Cash Resources
4. LIC 610- Emergency Disaster Plan
5. Current Administrator's Certificate

No deficiencies issued during today's visit. This report was reviewed with the ADM, and a copy was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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