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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202064
Report Date: 05/29/2024
Date Signed: 05/29/2024 03:41:52 PM

Document Has Been Signed on 05/29/2024 03:41 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, INC.FACILITY NUMBER:
445202064
ADMINISTRATOR/
DIRECTOR:
JENNIFER CARRERAFACILITY TYPE:
735
ADDRESS:18 VALLECITOS LN.TELEPHONE:
(831) 761-8858
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 6CENSUS: 3DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jennifer CarreraTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Jennifer Carrera.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the facility kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA Marrufo observed a locked storage area for cleaning supplies. LPA observed the first aid kit and found it to be complete.

LPA Marrufo toured two out of two resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. The smoke detectors in each bedroom and in the hallway functioned properly when tested. The carbon monoxide detector also functioned properly when tested.

The resident bathroom water temperature at 105 F and had working lights and available soap and paper towels.

The Emergency Disaster Drill Log recorded the last drill on 03/03/2024. The Personal and Incidental Money Log was reviewed and found to be balanced. The Centrally Stored Medication Log was reviewed and found to be complete. The resident and staff records were reviewed and found to be complete.

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

This report was reviewed with Administrator Jennifer Carrera and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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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