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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202064
Report Date: 09/16/2022
Date Signed: 09/16/2022 11:52:40 AM

Document Has Been Signed on 09/16/2022 11:52 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, INC.FACILITY NUMBER:
445202064
ADMINISTRATOR:JENNIFER CARRERAFACILITY TYPE:
735
ADDRESS:18 VALLECITOS LN.TELEPHONE:
(831) 761-8858
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 6CENSUS: 3DATE:
09/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Mary StevensTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Mary Stevens.

During visit, the inside and outside of the facility were toured. The facility entrance had a visitor screening area. The facility bathroom had available soap and paper towels. Hand washing posters were posted in the bathroom. A perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days was observed. A 30-Day supply of PPEs were observed. Cleaning supplies were also observed.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Mary Stevens and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
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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