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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200918
Report Date: 11/17/2025
Date Signed: 11/17/2025 01:44:52 PM

Document Has Been Signed on 11/17/2025 01:44 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: 2DATE:
11/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator Michelle BayquenTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Michelle Bayquen. LPA stated the purpose of the visit. ADM states the facility has 2 residents. LPA observed 1 resident and 1 staff.

LPA toured the interior and exterior of the facility with ADM to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction.

LPA toured the 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 observed the kitchen cabinets and drawers to have dark areas around the handles, and spider webs hanging from light fixtures and overhead cabinets. LPA observed the chemicals and knives storage areas were not locked and accessible to residents.

The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. Fire extinguishers were last serviced on 8/13/2025. ADM stated she did not have documentation of fire drills.

LPA inspected 2 resident bathrooms. LPA observed the bathrooms did not have hand-soap and paper towels. LPA advised ADM to ensure resident bathrooms have hand-soap and paper towels. LPA observed dark stains in the resident showers, and brown staining on the sinks and around the toilets. LPA also observed cobwebs throughout the bathroom ceilings.

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NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 435200918
VISIT DATE: 11/17/2025
NARRATIVE
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LPA toured 2 resident rooms. LPA observed Resident Room #1 to have papers, clothing, beddings, and medications on the ground. LPA also observed a catheter bag with unknown liquid in an uncovered trash bin. Based on review of R1's physician's report, R1 cannot administer his/her own medications. In Resident Room #2 LPA observed 2 measuring cups on a dresser, with one cup containing brown liquid, and the other cup containing blue liquid with a dead inside inside. Staff S1 stated he/she did not know what the liquids were in the cups. ADM removed the cups with unknown liquids during inspection.

Throughout the facility, LPA observed dark staining on the walls, cabinets, flooring of all rooms, bathrooms, kitchen and doorways. LPA advised ADM to ensure staff are cleaning to maintain sanitary conditions for residents, visitors and staff.

LPA reviewed 2 resident records.

LPA reviewed 2 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s).

LPA reviewed 3 staff records. 2 Out of 3 staff were associated and fingerprint cleared to the facility. Staff S1 is not associated to the facility. LPA reviewed S1's name in Guardian and S1 is not fingerprint cleared. S1 stated he/she has not done his/her fingerprints (LiveScan). LPA advised ADM to have S1 fingerprinted and associated to the facility, and S1 cannot work at the facility until he/she has obtained a background fingerprint clearance and is associated to the facility.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S1 working in the facility without receiving a criminal record background clearance. See LIC421BG.

LPA also recommended ADM to Community Care Licensing Division's Technical Support Program (TSP). LPA provided ADM with a TSP pamphlet.

Deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Administrator Michelle Bayquen and a signed copy of this report and appeals rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/17/2025 01:44 PM - It Cannot Be Edited


Created By: Marcella Tarin On 11/17/2025 at 12:34 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: 11/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that resident room #1 and #2 were observed with papers, medications, bedding on the floor, and unknown liquids on a dresser which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2025
Plan of Correction
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Licensee will submit a plan of correction regarding how the facility will ensure staff are keeping the facility clean, safe and sanitary at all times. Licensee will submit POC by POC due date 11/18/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/17/2025 01:44 PM - It Cannot Be Edited


Created By: Marcella Tarin On 11/17/2025 at 12:34 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: 11/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. ADM states she did not have documentation of staff training for 3 staff for 2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2025
Plan of Correction
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Licensee will submit a plan of action regarding how the facility will ensure 3 staff will obtain trainings for 2025. Licensee will submit POC to CCL by POC due date 12/2/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/17/2025 01:44 PM - It Cannot Be Edited


Created By: Marcella Tarin On 11/17/2025 at 12:42 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: 11/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
§1569.695 Emergency Plans
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the licensee did not comply with the section cited above in not conducting fire drills quarterly for each shift which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2025
Plan of Correction
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Licensee will submit POC addressing how the facility will conduct a drill at least quarterly for each shift. Licensee will submit POC to CCL by POC due date 11/18/2025. Licensee will conduct a drill by 11/20/2025, and submit documention of drill to CCL by 11/21/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/17/2025 01:44 PM - It Cannot Be Edited


Created By: Marcella Tarin On 11/17/2025 at 12:54 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: 11/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(b)
87309 Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above, the knives and chemical storage areas in the kitchen were not locked and were accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2025
Plan of Correction
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ADM will submit a plan of action on how the facility will lock away sharps and chemicals and they are not accessible to residents in care. Licensee will submit POC to CCL by 11/18/2025.
Type A
Section Cited
CCR
87355(e)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. S1 had not obtained a criminal record clearance before working in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2025
Plan of Correction
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ADM stated she will have S1 fingerprinted and associate S1 to the facility. ADM stated she will send a written plan of action on how she will ensure staff are ffingerprinted and associated to the facility. ADM stated she will send this written plan of action by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2025


LIC809 (FAS) - (06/04)
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