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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202812
Report Date: 05/11/2022
Date Signed: 05/11/2022 02:18:52 PM

Document Has Been Signed on 05/11/2022 02:18 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
CCLD Regional Office, 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: 6DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Thuy and Anthony TranTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the annual inspection to focus on infection control and met with Licensee and Administrator Thuy and Anthony Tran.

During visit, LPA toured the inside and outside of the facility to include the entrance, living room, dining room, kitchen, resident rooms, bathrooms, garage, and backyard.

Facility has a designated entry point. Hand sanitizer was made available. LPA advised to implement COVID-19 symptom screening and sign-in to initiate at the entrance for all visitors and staff. LPA advised facility to monitor resident and staff temperature daily. Bathrooms observed to be supplied with hygiene products and paper supplies. LPA observed facility to have a trash can with lid. LPA observed supply of Personal Protective Equipment (PPE). Facility staff clean and disinfect multiple times daily and as needed. Facility has a designated visitation area located in the backyard. LPA reviewed facility's policies and procedures to isolation and infection control training. The following signs were observed to include symptoms of COVID and prevent the spread of COVID.

LPA informed Administrator to submit Infection Control Plan to CCLD by 06/30/2022 and review PIN 22-13-ASC.

No deficiencies issued per the California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Thuy and Anthony Tran and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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