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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707505
Report Date: 11/14/2024
Date Signed: 11/14/2024 02:07:04 PM

Document Has Been Signed on 11/14/2024 02:07 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:
11/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Lead Staff Robert ForandaTIME VISIT/
INSPECTION COMPLETED:
02:20 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-20240312154828, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Lead Staff Robert Foranda

On March 14, 2024, LPA Simi Rai interviewed ADM. ADM stated on August 1, 2023, R1 was admitted to the facility and there was no wound on the foot. ADM stated on September 14,2023 R1 went to urgent care because of the cellulitis on the bottom of foot was infected and there was an open wound.

ADM stated on February 19, 2024, R1 went to urgent care. ADM stated on February 20, 2024, R1 was discharged back to the facility. ADM stated the Doctor had told her that the wound was superficial. ADM stated on February 26, 2024, the home health nurse saw the wound was infected and decided to call 911.

ADM stated she did not do assessment every time R1 came back from the hospital or Sunnyvale Post Acute. ADM did not visit R1 before R1 came back to the facility. ADM stated she would see R1 when R1 came back to the facility. ADM stated she did not document anything in the facility.

Based on a review of R1’s needs and Services Plan (ANS), dated August 1, 2023, the ANS has no mention of R1’s catheter or pressure injury.

Based on records reviewed and interview conducted, the Administrator did not update R1’s Needs and Services plan. R1 had sustained a wound on 09/14/23. ADM stated she did not do assessment every time R1 came back from the hospital.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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: 11/14/2024
NARRATIVE
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While investigating the complaint, LPA discovered that several incident reports were not sent to the Department regarding R1 hospitalization's.

Based on record Review, an incident report was received on March 13, 2024, which stated on September 14, 2023, R1 want to urgent care, after his/her nurse recommended further evaluation. Emergency room team admitted R1 with a diagnosis of cellulitis and blood clot of his/her right bottom foot with infection. Furthermore, the incident report states R1 was discharged from the hospital to Sunnyvale sub-acute and returned to the care home on November 26, 2023. Based on record review, this incident report was not sent to CCL.

Based on a review of the R1’s Record of Medial/ Dental care, R1 had a hospital visit on December 7, 2023, due to right foot swollen. Based on record review, an incident report was not sent within 7 days, regarding R1 needing to go to the hospital regarding his/her swollen right foot on December 7, 2023.

Based on record Review, an incident report was received on March 12, 2024, which stated on December 25 to December 28, 2023, R1 was sent to the hospital for an infection behind his/her right leg. Based on a record review, this incident report was not sent to Community Care Licensing (CCL).

Based on Record Review, an incident report was received on March 13, 2024, which stated on February 26, 2024, R1’s home health nurse reported that R1 should go to the hospital because of his/her swollen/infected ankle. Furthermore, the incident report states on March 6, 2024, R1 was discharged from VMC to Sunnyvale sub-acute. Based on record review, an incident report was not sent within 7 days, regarding R1 needing to go to the hospital regarding his/her swollen infected ankle on February 26, 2024.

Based on records reviewed and interview, the facility did not submit an incident report for instances where R1 was sent to the hospital, which includes the following dates: 09/14/2023, 12/07/2023, 12/25/23-12/28/23, 02/26/2024

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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: 11/14/2024
NARRATIVE
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Based on the totality of the investigation for the complaint, 26-AS-20240312154828, the Administrator did not comply with the title 22 regulation, 80064 Administrator - Qualifications and Duties (a)(3) Knowledge of and ability to comply with applicable law and regulation.

On March 14, 2024, LPA Simi Rai interviewed ADM. ADM stated she did not do assessment every time R1 came back from the hospital or Sunnyvale Post Acute. ADM stated she did not visit R1 before R1 came back to the facility. ADM stated she would see R1 when R1 came back to the facility. ADM stated she didn't know she needed a care plan for R1's restricted health conditions since he/she was receiving home health services. ADM stated she did not document anything in the facility.

Based on a review of R1’s needs and Services Plan (ANS), dated August 1, 2023, the ANS has no mention of R1’s catheter or pressure injury.

Based on records reviewed, the Administrator did not send incident reports for R1, when R1 was sent to the hospital for the following dates: 09/14/2023, 12/07/2023, 12/25/23-12/28/23, 02/26/2024.


On September 28, 2024, the Department cited the facility under code section, 80061 Reporting Requirements(b), for not sending an incident report, for an incident that occurred on February 23, 2024. As a result of today’s findings, the department issued an immediate civil penalty of $250 for a repeat violation.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with ADM CANONIZADO, via phone call. ADM stated Lead Staff Robert Foranda could sign on her behalf. 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: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/14/2024 02:07 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/14/2024 at 01:21 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: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2024
Section Cited
CCR
85068.3(a)

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85068.3 Modifications to Needs and Services Plan (a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently … to document significant occurrences that result in changes in the client's physical…
This Requirement was not met as evidenced by;
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ADM stated she will send a letter of understanding regarding the regulation.
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Based on records reviewed and interview conducted, the Administrator did not update R1’s Needs and Services plan. R1 had sustained a wound on 09/14/23. ADM stated she did not do assessment every time R1 came back from the hospital. 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 Correction by POC date, November 15, 2024.
Type A
11/15/2024
Section Cited
CCR80064(a)(3)

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80064 Administrator Qualifications and duties (a) (3) Knowledge of and ability to comply with applicable law and regulation.

This Requirement was not met as evidenced by;
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ADM stated she will send a letter of understanding regarding the regulation.
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Based on the totality of this complaint investigation, the ADM did not comply with the regulation above. ADM stated she did not do assessment every time R1 came back from the hospital and didn't know she needed a care plan for R1's restricted health conditions. 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 Correction by POC date November 15, 2024
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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/14/2024 02:07 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/14/2024 at 01:26 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: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2024
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 letter of understanding regarding the regulation and note how she will ensure incident reports are reported to Community Care Licensing.
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Based on records reviewed and interview, the facility did not submit an incident report for instances where R1 was sent to the hospital, which includes the following dates: 09/14/2023, 12/07/2023, 12/25/23-12/28/23, 02/26/2024 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 Correction by POC date, November 21, 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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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