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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202892
Report Date: 04/07/2023
Date Signed: 04/07/2023 12:15:36 PM


Document Has Been Signed on 04/07/2023 12:15 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:EVERGREEN SENIOR LIVINGFACILITY NUMBER:
435202892
ADMINISTRATOR:LADWIG, IRISHFACILITY TYPE:
740
ADDRESS:3703 YERBA BUENA AVETELEPHONE:
(408) 821-2630
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 0DATE:
04/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Irish LadwigTIME COMPLETED:
12:17 PM
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Licensing Program Analysts Ryker Heberle and Manuel Monter (LPAs) conducted an announced pre-licensing inspection on 04/07/2023 at 10:03am. LPAs met with facility Administrator Irish Ladwig (Admin).

During visit, LPA toured the facility, including living room, staff room, 6 resident bedrooms, laundry room, kitchen/dining room 4 bathrooms, and backyard. The facility is not currently operating and does not have any admitted clients. Facility was observed to be clean and in good repair. Fire exit routes were clear and free of obstructions. Carbon monoxide detectors was tested and observed to be functioning properly. Fire extinguisher was purchased in January of 2023. Bathroom hot water temperature was measured at 107.1*F. Facility temperature observed to be 67*F. Bathrooms were observed to be stocked with soap and paper towels. Showers were observed to have grab bars and nonskid mats. First Aid Kit observed to be complete. No open bodies of water noted at facility.

Medication cabinet observed to be locked. Facility kitchen equipment is functioning properly, LPAs observed locked drawer for sharps. LPAs reviewed emergency disaster plan and confirmed its completeness. LPAs observed storage closed for containment of cleaning chemicals. LPAs observed facility drying machine to not currently be functioning. Set of emergency keys has not yet been created by Administrator. Facility bulletin board contain all necessary documents.

Component III orientation was waived for this facility due to Administrator's prior experience. The physical plant is approved pending the creation of emergency key ring, submission of proof of operational drying machine, and completion of Centralized Application Bureau (CAB) review of the facility application. Exit interview was conducted and a copy of this report was provided to Irish Ladwig, Administrator. Report provided via email due to printer error.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
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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