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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707505
Report Date: 08/08/2025
Date Signed: 08/08/2025 05:41:07 PM

Document Has Been Signed on 08/08/2025 05:41 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:EVERGREEN GUEST HOME #2FACILITY NUMBER:
430707505
ADMINISTRATOR/
DIRECTOR:		CANONIZADO, E. & F.FACILITY TYPE:
735
ADDRESS:1628 MCLAUGHLIN AVENUETELEPHONE:
(408) 286-5985
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: 6DATE:
08/08/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Administrator Evelyn CanonizadoTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
NARRATIVE
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Licensing Program Analyst Manuel Monter conducted an unannounced case management visit-incident regarding an incident report, which stated a resident had eloped from the facility. LPA also addressed issues uncovered during the investigation for the complaint, 26-AS-20250617164444. LPA explained the purpose of the visit. ADM stated via phone call that staff, Lolita Ignacio could sign on her behalf.

Elopement- July 13, 2025

On July 14, 2025, the Department received an incident report regarding a resident (referred as R1) who eloped from the facility. According to the report, on July 13, 2025, at around 3:30pm, R1 yelled and walked out the house “going so fast.” Staff followed AR1, but he/she was so fast and staff lost sight of R1. Staff continued to look for R1 but couldn’t see him/her anymore. Staff came back and reported he/she lost track of R1. At around 5:09pm, ADM reported to police R1 as missing. Around 5:33pm staff went out for a walk and found R1 sitting under street along McLaughlin Ave.

On July 14, 2025, Licensing Program Analyst Christine Kabariti interviewed ADM. ADM stated 3 years ago, R1 would always elope from the facility, but it had lessened. ADM stated regarding R1 eloping on July 13, 2025, around 3:30pm R1 walked out the facility fast and staff tried to follow him/her but R1 was so fast the staff lost sight of R1. ADM stated around 5:33pm, staff found R1 sitting under a tree along Mclaughlin Ave, and R1 was brought back to the facility.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2025
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: EVERGREEN GUEST HOME #2
FACILITY NUMBER: 430707505
VISIT DATE: 08/08/2025
NARRATIVE
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On July 15, 2025, LPA Monter interviewed R1. R1 stated he/she did leave the home on July 13, 2025, around 3:30pm. R1 stated he/she was upset that his/her family member didn’t come to visit him/her. R1 stated his/her family member was supposed to bring him/her food. R1 stated he/she left thru the front door. R1 stated Staff at the care home saw that he left. R1 stated staff told him/her to go in, but R1 left. R1 stated nobody followed him/her.

R1 stated when he/she left the home & went to the story road. R1 stated he/she went towards Emma Prusch Farm Park, walking by him/herself. R1 stated he/she was near a park and a staff person found him/her and walked him/her back.

On July 18 and July 19, 2025, LPA Monter interviewed staff S1-S3. S1 stated regarding the elopement on July 13, 2025, R1 seemed upset, and he/she heard from his/her co-workers that R1 was upset at his/her family member because they did not bring the food that R1 wanted to eat. S1 stated this happened before and R1 tried to leave the facility but was stopped on time and redirected. S1 stated on July 13, 2025, around 3:30pm, S1 and S2 was preparing dinner to be served to the residents, when the door alarm went off. S1 went out to look and saw R1 walking fast. S1 stated he/she followed and R1 began yelling and screaming and picked up a rock to throw at S1. S1 stated he/she stopped, because he/she was worried if R1 did throw a stone at him/her, R1 might hit other people around him/her. S1 stated he/she went back to the facility and called the ADM and stated this is when he/she lost sight of R1. S1 spoke to ADM who told S1 to look for R1 at the Korean Church or at the park near McLaughlin and Story. S1 stated at 3:55 p.m. he/she went back to the facility because S1 needed to leave at 4:00 p.m. to report for his/her other job. S1 stated his/her co-worker S2 went out to find the resident, at this time another staff S3 came in before S1 left.

Staff S2 stated on July 13, 2025, he/she arrived at the facility at 1:00pm, resident R1 was already gone. S2 stated S1 was not able to follow R1 right away. S2 stated S1 follow R1 after 10-25 minutes and could not find R1. S2 stated he/she went to look for R1 at 3:30pm, but eventually returned to the facility when R1 wasn’t found. S2 stated staff S3 found R1 around 5:30pm.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC809 (FAS) - (06/04)
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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: EVERGREEN GUEST HOME #2
FACILITY NUMBER: 430707505
VISIT DATE: 08/08/2025
NARRATIVE
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Staff S3 stated on July 13, 2025, R1 left the facility around 1:30pm and S1 followed. S3 stated he/she told S1 to call the administrator, but S1 didn’t bring his/her cell phone. S3 stated S1 came back to the facility and called the administrator via landline. S3 stated the administrator said to follow R1. S3 stated he/she found R1 next to a tree on story road and brought him/her back to the facility around 5:00pm.

Based on a review of R1’s Physician’s report, dated April 16, 2025, R1 cannot leave the facility unassisted.

Based on a review of R1’s Individual Program Plan, dated January 18, 2024, R1 is unable to travel in the community by him/herself. R1 had a history of going AWOL.

Violations discovered during the investigation process. (26-AS-20250617164444).

On June 25, 2025, LPA Manuel Monter interviewed staff S1-S3. LPA asked S1 if he/she asks the residents what activities they want to do. S1 stated no. S1 stated some residents don’t speak English. S1 stated he/she cannot ask him/her what activities he/she would like to do.

On July 29, 2025, LPA interviewed ADM. ADM stated there is no staff currently scheduled who can speak Vietnamese.

Based on a review of the facility program, page 4 states, “there will be at least one direct care staff on duty during waking hours that speaks Vietnamese.”

LPA spoke with ADM. LPA informed ADM that is she isn't available, the licensee, Florencio Canonizado must be available in her stead, as he is also a licensee. Both licensees live outside the area in Merced. LPA requested a copy of the facility's current LIC500, with the availability of both licensees.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC809-D.

This report was reviewed with Administrator Evelyn Canonizado and a copy of the report was provided. Appeal Rights was provided. Page 3 Out of 3.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 08/08/2025 05:41 PM - It Cannot Be Edited


Created By: Manuel Monter On 08/08/2025 at 04:58 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: EVERGREEN GUEST HOME #2
FACILITY NUMBER: 430707505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2025
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidence by:
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Administrator stated he will send a written plan of action on how the facility ensures residents with wandering behaviors will be kept safe.
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Based on interviews and records reviewed, on July 13, 2025, Resident R1 left the facility unassisted. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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 ADM stated he will also send a written letter of understanding regarding the regulation.

ADM stated he will send the Plan of Action by POC date
Type A
08/09/2025
Section Cited
CCR80065(a)

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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced by:
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ADM stated she will conduct a staff training for her staff. ADM stated the training will be how to meet the care and supervision needs of residents with elopement behavior and residents who are actively eloping.
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Based on interviews and records reviewed on July 13, 2025, Resident R1 left the facility unassisted. S1 admitted when he/she was following R1, as he/she stopped following R1, and went back to the facility. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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ADM stated he will send the Plan of correction by POC date, August 9, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/08/2025 05:41 PM - It Cannot Be Edited


Created By: Manuel Monter On 08/08/2025 at 05:04 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: EVERGREEN GUEST HOME #2
FACILITY NUMBER: 430707505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2025
Section Cited
CCR
80022(k)

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 80022 Plan of Operation (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.
This requirement was not met as evidenced by:
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ADM stated she will submit a written plan of action on how she will ensure she is following her plan of operation.

ADM stated she will send the written plan of action to LPA by POC date August 15, 2025.
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Based on interview conducted, ADM stated the facility doesn’t have any staff that speak Vietnamese. The plan of operation states there will be at least one direct care staff that speaks Vietnamese. This poses a potential Health, Safety, or 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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
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