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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202782
Report Date: 10/21/2022
Date Signed: 10/21/2022 03:43:47 PM


Document Has Been Signed on 10/21/2022 03:43 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: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: 6DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Evonne EvienTIME COMPLETED:
03:46 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection. LPA met with facility administrator Evonne Evien (Admin).

LPA toured the facility, including 3 resident rooms, 1 staff room, kitchen, dining room, 2 living rooms, laundry room, garage, 2 bathrooms and back yard. LPA had their temperature taken and staff screened for symptoms. Admin confirmed that all staff and residents have been vaccinated.

Facility infectious control plan has already been submitted. Medication observed in 1 resident's (R1) room. Review of resident file indicated that R1 was not cleared by doctor to store his own medication. Admin stated that R1's physician agreed that R1 was allowed to store and administer his own PRNs. LPA contacted R1's physician, Dr. Kenneth R. Wulff, who verbally confirmed that R1 is allowed to administer his own PRN medication, and that they would be sending over a doctor's note/updated physician's report for the facility's records.

All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to be inspected in March of 2022. 30 day supply of PPE observed. All restrooms stocked with paper towels. Water temperature observed to be 125.7 *F. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. The facility is currently accepting visitors inside the facility, including residents' bedrooms.

Deficiency cited during today's visit. See 809-D. This report was reviewed with Administrator Evonne Evien and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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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Document Has Been Signed on 10/21/2022 03:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: EVONNE'S RESIDENTIAL CARE FACILITY #3
FACILITY NUMBER: 435202782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 - Maintenance and Operation - (e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 bathroom sink tested. which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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Licensee to adjust water temperature into acceptable levels and to provide daily water temperature log to The Department by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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