<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202812
Report Date: 09/30/2023
Date Signed: 09/30/2023 11:48:28 AM

Document Has Been Signed on 09/30/2023 11:48 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EVERGREEN HOMEFACILITY NUMBER:
435202812
ADMINISTRATOR:TRAN, ANTHONYFACILITY TYPE:
735
ADDRESS:5991 SOUTH SURF CT.TELEPHONE:
(408) 677-4520
CITY:SAN JOSESTATE: CAZIP CODE:
95138
CAPACITY: 6CENSUS: 3DATE:
09/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator Anthony TranTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Thuy Tran. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included; the Living room, kitchen, dinning room, garage, two restrooms, staff room and 3 residents bedrooms. Front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the residents bedrooms, LPA observed 2 windows without screens in bedroom 3. ADM stated one of the residents has a behavior of pushing objects thru the window and pushing the screen as well. ADM stated she has notified SARC as well about this. LPA observed the window in bedroom 2 with a damaged window screen as well.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication cabinet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degree F, and hot water temperature was measured at 108 degrees F in the upstairs bathroom and 106 degrees F in the downstairs bathroom. Fire extinguisher was serviced in September 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 09/21/2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff (S1 to S2) and 2 residents (R1-R2).

Deficiencies are being cited during today's visit. See LIC809D. This report was reviewed with Administrator Thuy Tran and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2023
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
Document Has Been Signed on 09/30/2023 11:48 AM - It Cannot Be Edited


Created By: Manuel Monter On 09/30/2023 at 11:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EVERGREEN HOME
FACILITY NUMBER: 435202812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation & interview, the licensee did not comply with the section cited above. LPA observed bedroom #3 with no window screens. LPA also oberved bedroom #2 with a damaged screen. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2023
Plan of Correction
1
2
3
4
ADM stated she will send a plan of action to keep window screens in good repair. ADM stated she will send to LPA by 10/07/2023.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2