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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 011405820
Report Date: 08/25/2022
Date Signed: 08/25/2022 11:20:36 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/17/2022 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220817081011
FACILITY NAME:EVERGREEN PROGRAMFACILITY NUMBER:
011405820
ADMINISTRATOR:LOPEZ, VERONICAFACILITY TYPE:
775
ADDRESS:797 MONTAGUE AVENUETELEPHONE:
(510) 895-2838
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:150CENSUS: 17DATE:
08/25/2022
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Veronica Lopez, Program DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility not accepting client into the program
INVESTIGATION FINDINGS:
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On 8/5/2022 at 10:05 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct the complaint investigation for the above allegation. LPAs met with Program Director, Veronica Lopez and explained the purpose of the visit.

During the complaint investigation, LPAs interviewed staff and obtained documents. Based on information obtained, facility is not accepting client into the program for not being fully COVID-19 vaccinated. Record review of admission procedures indicates that all participants that attend the day program should be fully vaccinated which is in violation of PIN 22-23-ASC.

Based on LPAs interview and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted with Program Director. Appeal rights and a copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20220817081011
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: EVERGREEN PROGRAM
FACILITY NUMBER: 011405820
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2022
Section Cited
CCR
82072(a)
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82072 PERSONAL RIGHTS
(a) Each client shall have personal rights which include, but are not limited to, the following:

This requirement is not met as evidenced by:
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Administrator agrees to allow client to attend in-person and review PIN 22-23-ASC and submit self-certification letter to CCLD by POC
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Based on interview and record review, Licensee did not comply with the regulations cited above. C1 was not allowed to participate for in-person due to COVID-19 vaccination status which poses a personal rights 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2