435202663-8-4-2021-26-AS-KHOS-C68R49-20210825124111

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202663
Report Date: 08/03/2021
Date Signed: 08/04/2021 10:25:11 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2021 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210728081426

FACILITY NAME:	EVERGREEN HOME LIVING		FACILITY NUMBER:	435202663
ADMINISTRATOR:	KUMAR, SASHI		FACILITY TYPE:	740
ADDRESS:	3291 SYLVAN DR		TELEPHONE:	(408) 459-7888
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY:	6	CENSUS: 4	DATE:	08/03/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Ian Sumbi		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Facility had insufficient food supply

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced initial investigation visit. LPA met with the House Manager Ian Sumbi.

LPA interviewed 2 residents. 2 out of 2 residents stated they were provided enough food in the facility.

LPA interviewed 3 staff. 3 out of 3 staff stated there was sufficient food in the facility for residents.

LPA toured the facility. LPA inspected the refrigerator and the pantry storage. LPA estimated there were at least 2 days of perishable and more than 7 days of nonperishable foods in the refrigerator and the pantry respectively.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210728081426

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/03/2021

NARRATIVE

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This Department has investigated the above allegation. Based on interviews and observations, the Department found that the above allegation is UNSUBSTANTIATED. Unsubstantiated finding indicated that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

This report was reviewed with House Manager and a copy of this report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

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