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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202663
Report Date: 05/20/2022
Date Signed: 05/20/2022 04:56:14 PM

Document Has Been Signed on 05/20/2022 04:56 PM - It Cannot Be Edited

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:NGUYEN, THUFACILITY TYPE:
740
ADDRESS:3291 SYLVAN DRTELEPHONE:
(408) 459-7888
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 6CENSUS: 5DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Thu NguyenTIME COMPLETED:
04:13 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Licensee (LNS) Thu Nguyen. upon arrival, LNS took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside out with LNS. COVID posters were observed at main entrance and in the facility. Screening station at the main entrance with masks, hand sanitizer, thermometer and visitor log book was observed. Living room, kitchen, dinning room, family room and two restrooms were inspected. Some trash cans were observed without covers. LNS stated facility will replace the trash cans with covers in 3 days. Paper towel were observed with holders. Cloth towels were observed at kitchen and restrooms. Three single resident bedrooms and 1 shared resident room were inspected. One staff live-in room is in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 108 degree F in facility. Five residents and one staff were observed in facility.

Fire extinguisher was serviced on 6/03/2021. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. LNS tested the smoke detectors, and they were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

LNS stated all the residents and staff are fully vaccinated and done with booster. No citation were noted today. Exit interview was conducted with LNS. This report was provided to LNS for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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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