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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707505
Report Date: 09/28/2024
Date Signed: 09/28/2024 05:29:26 PM

Document Has Been Signed on 09/28/2024 05:29 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:
09/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Lead Staff Robert ForondaTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation. During the complaint investigation for the complaint 26-AS-20230310144550, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Lead Staff Robert Foronda

While investigating the complaint , LPA discovered that an incident report was not given to the Department regarding R1 running to the front of the home on February 23, 2023.

Based on interviews with ADM, Staff S1 and S2, resident R1 did run to the front of the home on February 23, 2023. Staff S1 stated R1 was having a behavior that day and had struck one of the staff and ran towards the front door. S1 stated he/she followed R1 outside. S1 stated when he/she was chasing after R1, S1 stated he/she was also trying to call out and redirect R1 back to the home. S1 stated he/she followed R1 until R1 had calmed down and redirected R1 back home. S1 stated he/she followed R1 and R1 was not left unsupervised.

Staff S2 stated he/she was staying in the staff room sleeping (live in staff). S2 stated he/she heard some noise and exited the staff room to investigate. S2 stated he saw R1 throw small speaker and he/she tried to intervene but R1 threw it. S2 stated R1 went outside and (S1) followed him/her. S2 stated S1, brought R1 back.

On September 28, 2024, LPA interviewed ADM. ADM confirmed that on February 23, 2023, resident R1 had run to the front of the home, while staff S1 had followed him. ADM stated she doesn't know if she sent an incident report to Community Care Licensing. (CCL). ADM stated she doesn't have the records and does not know
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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
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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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: 09/28/2024
NARRATIVE
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Based on a review of the Department records, the facility did not send an incident report regarding this incident.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with staff Sofia Pansalin and a copy of the report was provided. Appeal rights were provided.

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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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/28/2024 05:29 PM - It Cannot Be Edited


Created By: Manuel Monter On 09/28/2024 at 04:25 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: 09/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2024
Section Cited
CCR
80061(b)

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80061 Reporting Requirements (b) Upon the occurrence... a report shall be made to the licensing agency ...shall be submitted to the licensing agency within seven days following the occurrence of such event.
This Requirement was not met as evidenced by;
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ADM stated she will send a written plan of action on how she will ensure incident reports are sent to Licensee within 7 days. ADM stated she will also send a letter of understanding regarding the regulation.
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Based on records reviewed and interview, the facility did not submit an incident report for the incident, on 2/23/2023 where R1 ran to the front of the home, with staff S1 following. This poses an immediate health, safety or personal rights risk to persons in care.
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ADM stated she will send the Plan of Corrections 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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