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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202754
Report Date: 08/22/2023
Date Signed: 08/23/2023 09:08:01 AM


Document Has Been Signed on 08/23/2023 09:08 AM - 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:PRIMAVERA GARDENSFACILITY NUMBER:
435202754
ADMINISTRATOR:MICHAEL ELSOUSOUFACILITY TYPE:
740
ADDRESS:16095 CHURCH STREETTELEPHONE:
(408) 778-5683
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:20CENSUS: DATE:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:NICK ELSOUSOUTIME COMPLETED:
05:25 PM
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Licensing Program Analysts (LPAs) Steve Chang and Emanuel Monter conducted an unannounced annual inspection visit, and met with Administrator Assistant (AA) NICK ELSOUSOU.

LPAs checked 3 residents files and 3 staff files. LPA's interviewed 4 staff and 8 residents.

LPAs toured the facility inside out with AA. License and Personal Rights posters were observed at the main entrance. Living room, dining room, kitchen, 13 resident bedrooms, 1 staff room, i office, 4 restrooms, and laundry room were inspected. Nonskid pads were observed in the restrooms. Medication closet, detergent closet, and knives closet were observed locked. All the bedrooms were observed with window screens. First Aid kit was observed in facility.

Two day perishable food supplies and Seven day nonperishable food supplies were observed sufficient. Room temperature was observed at 78 degree F. Hot water temperature was measured to range from 118-119 degree F. Refrigerator temperature was observed at 40 degree F. Freezer temperature was observed at 0 degree F.

Fire extinguisher was serviced on 05/08/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. LPAs toured backyard and front yard with AA. There is no obstruction to block exit at the backyard.

No deficiencies were noted today. Exit interview was conducted with AA. The report was provided to AA for signature. A copy of the report was provided to AA.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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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