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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202782
Report Date: 09/30/2020
Date Signed: 09/30/2020 03:28:17 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:EVONNE'S RESIDENTIAL CARE FACILITY #3FACILITY NUMBER:
435202782
ADMINISTRATOR:EVIEN, EVONNEFACILITY TYPE:
740
ADDRESS:2941 PENITENCIA CREEK ROADTELEPHONE:
(408) 702-7325
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:6CENSUS: 0DATE:
09/30/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Evonne Evien, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jackie Jin conducted an announced Pre-licensing Tele-visit due to COVID-19 health pandemic. LPA met with Evonne Evien, Administrator via ZOOM.

The facility is a brand new facility with no residents in care. The facility has an approved fire clearance for 6 nonambulatory residents.

The facility was toured inside and outside including the bedrooms, bathroom, common areas, and the kitchen. The facility is clean and in good repair. Bedrooms are equipped with proper furniture such as a bed, night stand, reading lamp, a chair, and a closet of drawers. Bathroom is equipped with grab bars and nonskid floors. Bathroom also have hygiene times and toiletries. Common areas have furniture and activities available. Hot water temperature is maintained between 105-120 degrees Fahrenheit. Centrally stored medication closet, sharp objects, and toxins were locked. First aid kit is complete. Linens and towels were observed.

Kitchen area was observed clean and sanitary. 2 days worth of perishables and 7 days worth of nonperishable were observed. Refrigerator temperature is maintained at 35 degrees Fahrenheit and freezer temperature is maintained at 0 degrees Fahrenheit. Kitchen area has cups, plates, and utensils for residents to use.

Facility has a laundry area. Laundry supplies will be available when the facility has residents.

Facility is equipped with interconnected smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced on 08/12/2020. Hallways and passageways were free of obstruction.

Facility has sample files of staff records, resident records, and centrally stored medication records.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: EVONNE'S RESIDENTIAL CARE FACILITY #3
FACILITY NUMBER: 435202782
VISIT DATE: 09/30/2020
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The following posters were observed: If You See Something Say Something, Residents Right To Counsel, and Personal Rights.

COMP III is being waived because the Administrator has been an Administrator since August 2019.

No issues noted during this pre-licensing inspection. LPA observed the facility is ready to be licensed. However, this report will be submitted to the Centralize Application Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

This report was reviewed with Evonne Evien, Administrator, and a copy of this report will be emailed to Evonne Evien, Administrator on 09/30/2020 for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020
LIC809 (FAS) - (06/04)
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