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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202663
Report Date: 06/28/2024
Date Signed: 06/28/2024 05:45:24 PM


Document Has Been Signed on 06/28/2024 05:45 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
CENTRAL COAST CR/RES, 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: 0DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Licensee/ Administrator, Thu NguyenTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Licensee/ Administrator, Thu Nguyen. LPA Rai did not observe staff or residents at the facility. This facility is currently non-operational.

Licensee/ Administrator, Thu Nguyen stated this facility is level 4f and accepts residents overseen by San Andreas Regional Center.

LPA Rai observed the electricity, water and kitchen appliances were working and in use during the visit.

Licensee/ Administrator, Thu Nguyen is aware the Licensee will continue to pay the annual fee and facility cannot be rented out as the location is still a facility. Licensee/ Administrator, Thu Nguyen provided LPA Rai a copy of the check sent to the Program office for 2024 annual fee which was mailed out 6/26/2024.

Licensee/ Administrator, Thu Nguyen agreed and understood that the facility is in active status, therefore, they are not exempted from not adhering to Title 22, Division 6 Policy, Regulations, and Laws on RCFEs.

LPA advised to inform the Community Care Licensing Regional Office when the first client has been admitted to the facility.

No deficiencies were cited at this time as per California Code of Regulations, Title 22.

This report was reviewed with Licensee/ Administrator, Thu Nguyen and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
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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