430707505-9-28-2024-26-AS-KHOS-D9LRGD-20240930130034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430707505
Report Date: 09/28/2024
Date Signed: 09/28/2024 03:50:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2022 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20221007160223

FACILITY NAME:	EVERGREEN GUEST HOME #2		FACILITY NUMBER:	430707505
ADMINISTRATOR:	CANONIZADO, E. & F.		FACILITY TYPE:	735
ADDRESS:	1628 MCLAUGHLIN AVENUE		TELEPHONE:	(408) 286-5985
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95122
CAPACITY:	6	CENSUS: 6	DATE:	09/28/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Lead Staff Robert Foronda		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident was physically assaulted while in care of facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Lead Staff Robert Foronda.

On October 7, 2022, the Department received a complaint alleging Resident was physically assaulted while in care of facility. It has been alleged resident R1 had been struck in the face on October 3, 2022.

On September 10, 14, and 22, 2024, Licensing Program Analyst Manuel Monter interviewed staff S1 -S4. Staff S1, S3 and S4 stated they did not observe any staff or residents hitting R1. Staff S2 stated he/she did not work in the facility in October 2022 but stated staff don’t hit residents and residents don't hit each other because the staff watch them.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20221007160223

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: EVERGREEN GUEST HOME #2	FACILITY NUMBER: 430707505
	VISIT DATE: 09/28/2024

NARRATIVE

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On September 14, 2024, LPA Monter interviewed residents R2-R6. 2 Out of 5 residents (R3 & R6) stated the staff don’t hit the residents and the residents do not hit each other. 1 Out of 5 residents (R5) stated they don’t know if staff or residents hit other residents. 2 Out of 5 residents interviewed were unable to provide answers to LPA's questions. Residents interviewed had behaviors such as not talking, ignoring questions, being distracted and engaging in other actions such as playing with toy/tablet.

On September 23, 2024, LPA Monter interviewed ADM. ADM stated staff and residents did not hit R1. ADM stated that never happened.

Based on Record review, the facility submitted an Incident Report to Community Care Licensing on October 5, 2022. The Incident Report was dated October 4, 2022. The Incident report stated on October 4, 2022, R1 was inside the bathroom with his/her cell phone. When R1 came out, a staff member was waiting for R1 to finish to take in another resident to use the restroom. The other resident reached his/her hand to the door of the bathroom. The Incident Report states R1 was not hit on his/her face by the other resident.

On October 7, 2022, the Department interviewed witness (W1). W1 stated on October 3, 2022, he/she had observed R1’s face and observed no injury.

The Department was unable to interview Resident R1, who no longer lives at the facility.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

This Report was reviewed with Lead Staff Robert Foronda. Facility Administrator stated she could not come to the facility and stated Lead Staff Robert Foronda could sign on her behalf.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024

LIC9099 (FAS) - (06/04)

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