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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801323
Report Date: 07/19/2022
Date Signed: 07/19/2022 01:24:36 PM


Document Has Been Signed on 07/19/2022 01:24 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:JT EVERGREEN CARE HOMEFACILITY NUMBER:
486801323
ADMINISTRATOR:COPERO, JOHNNYFACILITY TYPE:
740
ADDRESS:115 MICHAEL CRT.TELEPHONE:
(707) 557-0180
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Johnny CoperoTIME COMPLETED:
11:30 AM
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LPA A Canela arrived unannounced to conduct an Annual Required - 1 year inspection and met with Administrator, Johnny Copero. This inspection is focused on the Covid protocols of this facility.

Upon LPAs entrance to this facility and risk assessment, LPA received information the facility has Covid as of this morning. LPA went over PPE items to be available for staff when going into a residents room with a confirm case of Covid-19. Proper use of PPE, discarding used PPE, and facility cleaning and disinfecting. LPA observed a PPE station outside the bedroom for R1. The facility has sufficient PPE supplies but LPA was unable to complete inspection.

LPA will return to complete inspection at a later date.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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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