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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707505
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:41:22 PM

Document Has Been Signed on 09/10/2024 04:41 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:
09/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:05 PM
MET WITH:Lolita Ignacio StaffTIME VISIT/
INSPECTION COMPLETED:
04:06 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter and Marcela Yanez arrived unannounced to continue a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the visit LPA met with Lolita Ignacio.

During investigation LPAs observed two dozen ants on the wall crawling onto the dining room table LPAs and staff observed ants as well (photograph were taken)

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Staff Lolita Ignacio and Appeals rights were provided
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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Document Has Been Signed on 09/10/2024 04:41 PM - It Cannot Be Edited


Created By: Marcela Yanez On 09/10/2024 at 04:12 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: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2024
Section Cited
CCR
80078(a)(1)

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80078 Buildings and Grounds(a) The facility shall be clean, safe, sanitary and in good repair at all times...(1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement is not met evidenced by
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ADM will submit a written plan of ensure the facility is free of insects in the dining room table
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Based on observation LPA observed 2 dozen ants next to dining room table. This poses potential health and safety personal rights of residents in care
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ADM stated she will submit a written plan of action by August 17, 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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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