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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202782
Report Date: 09/24/2021
Date Signed: 10/12/2021 11:39:57 AM

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: 3DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Evonne EvienTIME COMPLETED:
10:40 AM
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Licensing Program Analyst, Steve Nguyen, conducted and unannounced 1 year annual inspection with Administrator, Evonne Evien.

LPA toured facility inside and out. LPA observed: Covid signs are present and in conspicuous vantage points, all exits are free of obstructions, emergency contact for residents were up to date, facility screening protocols will be enforce and staff will be retrained by AD, hand sanitizing station were available throughout facility, medicine cabinet were observed to be locked, paper towers are in use, all beds are at least 6 feet apart and physical distancing was observed to be in practice.

No citation was issued at this time.

LPA went over report findings with Administrator, Evonne Evien, for review and a copy was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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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