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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202663
Report Date:
09/15/2021
Date Signed:
09/15/2021 03:42:39 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:
KUMAR, SASHI
FACILITY TYPE:
740
ADDRESS:
3291 SYLVAN DR
TELEPHONE:
(408) 459-7888
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95148
CAPACITY:
6
CENSUS:
3
DATE:
09/15/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:15 PM
MET WITH:
Sashi Kumar and Thu Nguyen
TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Steve Nguyen conducted an inspection of facility with Administrator Sashi Kumar. LPA observed the windows and wall from one of the bedroom to be broken. LPA advised Licensee and Administrator that the window and wall needs to be fixed. Licensee acknowledged and confirmed understanding. Licensee gave the fix date as 9/20/2021 and will provide Department with pictures and/ or pictures with receipts upon completion.
SUPERVISOR'S NAME:
Jackie Jin
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Steve Nguyen
TELEPHONE:
(650) 676-0051
LICENSING EVALUATOR SIGNATURE:
DATE:
09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/15/2021
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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