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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202944
Report Date: 10/29/2024
Date Signed: 10/29/2024 11:58:50 AM

Document Has Been Signed on 10/29/2024 11:58 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 WEST - DIASFACILITY NUMBER:
435202944
ADMINISTRATOR/
DIRECTOR:		TRAN, ANTHONYFACILITY TYPE:
735
ADDRESS:3347 DIAS DRIVETELEPHONE:
(650) 868-2860
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 4CENSUS: 0DATE:
10/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Anthony TranTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analysts (LPAs) Marcela Yanez, and Manuel Monter arrived to conduct the pre-licensing inspection. LPA met with Anthony Tran . The facility is an Adult Residential Facility and has an approved fire clearance for (4) ambulatory.

During visit, LPAs toured the interior to include 4 resident bedrooms, 2 bathrooms, living room, kitchen, garage, backyard, and front yard. All fire exit routes are free and clear of obstruction. Fire extinguisher,purchased on 04/06/24 carbon monoxide detector, and complete first aid kit observed.

Interior temperature maintained between 74 - 76 degrees Fahrenheit. ADM stated the chemicals will be stored in the locked cabinet in garage that will be kept inaccessible to residents.Sufficient cups, plates, bowls, and utensils observed. Refrigerator temperature maintained at 39 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. Bedrooms equipped with beds, linens, adequate lighting, chair, night-stand, closet and dressers.

Hot water temperature in the bathroom maintained at 118.0 degrees Fahrenheit. Garage observed with laundry appliances and supplies. ADM stated the garage is being used as storage and laundry. Facility has an area to lock medications, records and flashlights. Posters observed to include the licensing complaint poster, personal rights and rights of resident council.

No issues noted during the pre-licensing inspection. LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Anthony Tran and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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