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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430707505
Report Date: 09/28/2024
Date Signed: 09/28/2024 05:22:33 PM

Substantiated


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
10/14/2022 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20221014072030
FACILITY NAME:EVERGREEN GUEST HOME #2FACILITY NUMBER:
430707505
ADMINISTRATOR:CANONIZADO, E. & F.FACILITY TYPE:
735
ADDRESS:1628 MCLAUGHLIN AVENUETELEPHONE:
(408) 286-5985
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:6CENSUS: 6DATE:
09/28/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lead Staff Robert ForondaTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility 1:1 staff lacks the capability and ability to redirect resident with behaviors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with Lead Staff Robert Foronda

On October 14, 2022, the department received a complaint alleging facility 1 on 1 staff, (S1) lacks the ability to redirect resident with behaviors.

On October 19, 2022, LPA Chang interviewed ADM. ADM stated staff (S1) worked at level 4i facilities before. ADM stated S1 worked at Evergreen guest Home #3 before which is a level 4i facility.

Page 1 Out of 2.
Substantiated
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)
Page: 1 of 5
Control Number 26-AS-20221014072030
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 October 19, 2022, LPA Chang interviewed S1. S1 stated S1 works for the facility since March 2022. S1 stated S1 did not received any 1 on 1 care training. S1 stated he/she has the experience in working at level 4i facilities before.

On September 14, 2024, LPA Monter interviewed residents R2-R6. 3 Out of 5 residents (R3, R5, R6) stated they didn’t know if staff S1 knew how to redirect resident R1. 2 Out of 5 residents (R2, R4) 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 10, 14 and 22, 2024, LPA Monter interviewed staff S2-S5. Staff S2 stated he/she was not there at the time and doesn’t know if staff S1 could redirect R1. Staff S3, S4 and S5 stated staff S1 knew how to redirect R1.

Based on a review of R1’s Individual Program Plan (IPP). Dated June 2, 2022, R1 has a history of being injurious to others, which has an average of 2 occurrences per day. R1 also has a history of property destruction.

LPA requested to review S1’s training. ADM stated she did not have any more documents of training. ADM stated she only had training documents from 2023 for S1. ADM stated she tell her staff to train, but they don't like to do it.

Based on interviews and evidenced reviewed the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with staff Sofia Pansalin and a copy of the report was provided. Appeal Rights was provided.

Page 2 Out of 2. END OF REPORT.
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)
Page: 2 of 5
Control Number 26-AS-20221014072030
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2024
Section Cited
CCR
80065(f)
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80065 Personnel Requirements (f) All personnel shall be given on-the-job training ...which provides knowledge of and skill in the following areas...as evidenced by safe and effective job performance.
This requirement was not met as evidenced by as;
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ADM stated she will send a written plan of action on how she will ensure her staff are trained annually. ADM stated she plan of action will address ensuring training's conducted are documented.
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Based on interview and record review, the facility did not provide any documentation of training staff S1 took for the year 2022. S1 stated he/she did not receive 1 on 1 training. ADM stated the 2023 training is all she can provide to LPA. This poses a potential health, safety or personal rights risk to persons in care.
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ADM stated she will send the written plan of action by POC date, October 5, 2024.
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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: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5