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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200918
Report Date: 03/17/2025
Date Signed: 03/17/2025 03:43:04 PM

Document Has Been Signed on 03/17/2025 03:43 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:EVCO CAREFACILITY NUMBER:
435200918
ADMINISTRATOR/
DIRECTOR:		MICHELLE BAYQUENFACILITY TYPE:
740
ADDRESS:3274 EVCO COURTTELEPHONE:
(408) 937-1625
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 3DATE:
03/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:08 PM
MET WITH:Thelma BlanchardTIME VISIT/
INSPECTION COMPLETED:
03:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted a case management - incident visit and met with Licensee (LCN) Thelma Blanchard.

On 3/12/2025, the Department received a notice that an altercation occurred between 2 resident (R1, R2).

LPA toured the facility with LCN. LPA interviewed Licensee, 1 residents (R1).

LCN stated on 3/12/2025, around 9:30AM, resident R1 sat at the dining table and R2 approached to the dining table. R1 and R2 had altercation. R1 pushed R2 away and R1 was leaning on the chair. LCN stated R2 did not fall down on the floor. LCN stated he/she talked to case manager around 11:30AM. R1 stated he/she does not remember what the date the incident occurred. R1 stated he/she pushed R2 away not hard. R1 stated after that he/she walked away from R2.

Based on the interview, the facility staff lack of supervision leading to altercation between resident R1 and R2, and R1 pushed R2 away.

Citation was issued today. See LIC809-D.

Exit interview was conducted with LCN. The reports were provided to LCN for review and signature. Appeal Rights and a copy of the report were provided to LCN.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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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Document Has Been Signed on 03/17/2025 03:43 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 03/17/2025 at 02:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EVCO CARE
FACILITY NUMBER: 435200918

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2025
Section Cited
CCR
87464(f)(1)

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87464 Basic Services(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

This requirement is not met as evidenced by:
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Licensee agreed to send a plan of correction by the POC due date to ensure to provide the necessary care and supervision to ensure the similare incident not to happen again.
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Based on interview, the facility did not provide the necessary care and supervision to resident R1 and R2 to meet their care needs and leading in that R2 pushed R1 which poses/posed an immediate Health, Safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
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