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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430707505
Report Date: 11/14/2024
Date Signed: 11/14/2024 02:09:04 PM

Unsubstantiated


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
03/12/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240312154828
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:
11/14/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Lead Staff Robert ForandaTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Due to staff neglect, a resident sustained an unstageable pressure injury while in care.
Staff did not ensure that a resident attended healthcare appointments.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint investigation to deliver the findings on the above allegations. LPA met with Lead Staff Robert Foranda

On March 12, 2024, the Department received a complaint alleging staff did not ensure that a resident attended healthcare appointments.

On September 14, 2024, LPA Monter interviewed Staff S1 and S2. S1 stated he/she did take R1 to his/her doctors’ appointments. S1 stated there hasn’t been a time when R1 was not taken to his/her doctors appointment. Staff S2 stated staff S1 takes R1 to his/her doctors’ appointments and stated there hasn’t been a time when R1 wasn’t taken to his/her doctors appointments.

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Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 26-AS-20240312154828
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: 11/14/2024
NARRATIVE
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LPA Monter interviewed residents R2-R6. R3 stated staff do take them to their doctors’ appointments. R5 stated he/she doesn’t know if staff take him/her to his/her doctors’ appointments. R6 stated his/her family member takes him/her to the doctors’ appointments. 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 28, 2024, LPA Monter interviewed ADM. ADM stated R1 has not missed his/her doctors’ appointment. ADM stated the facility has a written log for appointments R1 had attended.

On October 22, 2024, LPA Monter interviewed R1. R1 stated he/she missed 2-3 appointments with his/her doctor. R1 stated the staff wouldn’t take him/her because his/her appointments were in Los Gatos, and it was too far. R1 stated he/she does not know the dates of when he/she had missed his/her doctors’ appointments. R1 stated his/her Family member or Service coordinator would know what appointments he/she missed.

LPA interviewed R1’s Family member (FM). FM stated he/she is aware of the allegations but doesn’t know how many or when they were missed. FM stated R1’s services coordinator is the best person to contact as he/she has the information.

On October 30, 2024, LPA Monter interviewed R1’s Service Coordinator (SC). SC stated he/she does not know what medical appointments have been missed. SC stated he/she does not have R1's medical appointment records.

Based on a review of the facility’s record of medical dental, the facility took R1 to his/her appointments for the following dates. August 7,14,24 & 30, 2023. September 1, 2023. December 20 & 28, 2023. January 11, 26 and 31, 2024.

The Department has reviewed the complaint allegation. Based on information from interviews conducted, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Page 2 Out of 4.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20240312154828
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: 11/14/2024
NARRATIVE
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Due to staff neglect, a resident sustained an unstageable pressure injury while in care.

On March 12, 2024, the Department received a complaint alleging due to staff neglect, a resident sustained an unstageable pressure injury while in care.

On March 14, 2024, LPA Simi Rai interviewed Staff S1. S1 stated he/she was the caregiver assigned to Resident R1. S1 stated R1 had a wound on the right ankle. On February 19, 2024, at approximately 7am, R1 showed the wound to S1 and S1 took a picture and showed the Administrator. ADM asked staff to go to Urgent Care, so S1 transported R1 to Urgent Care. At Urgent Care, the Physician's Assistant advised R1 and S1 to go to Emergency room since they assessment of the wound was a stage 3 wound. S1 stated the paramedics came and transported R1 to the hospital and he/she was admitted overnight. S1 stated R1 came back to the facility on 2/20/2024 with new medication orders for antibiotics. S1 stated a couple of days later, R1's home health nurse called 911 to transport R1 back to the hospital.

S1 stated the right ankle was not wrapped and S1 was able to see the ankle. S1 stated, when referring to document the "After Visit Summary from September 14, 2023". S1 said R1 went to Sunnyvale Post acute for wound for 3 months. S1 stated the wound stage was also stage 3. S1 said he doesn't know of any issues with after R1 came back from Sunnyvale Post Acute in November.

On March 14, 2024, LPA Simi Rai interviewed ADM. ADM stated resident R1 was admitted to the facility on August 1, 2023. ADM stated when R1 moved to the facility, there was no wound on the foot.

ADM stated R1 went to urgent care on February 19, 2024, and was admitted to the hospital. ADM stated R1 was discharged back to the facility on February 20, 2024, resident discharged back to the facility. ADM stated the doctor at the hospital stated the wound was superficial. ADM stated she didn't know what that meant but she still admitted the resident back to the facility and the home health nurse was observing the wound. ADM stated on February 26, 2024, the home health nurse saw the wound was infected and decided to call 911. ADM stated R1 was transferred to Sunnyvale Post Acute.

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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
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20240312154828
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: 11/14/2024
NARRATIVE
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ADM stated she only spoke to R1's doctor at the time of discharge. ADM stated he/she did not do assessment every time R1 came back from the hospital or Sunnyvale Post Acute. ADM stated she didn't know she needed a care plan for the restricted health conditions since R1 was receiving home health services, and the facility staff did not touch the wound. ADM stated she did not document anything in the facility.

Based on record review of R1’s Individual Program Plan (IPP) dated October 31, 2023, R1 moved into Evergreen Guest home #2 on August 1, 2023. Page 6 of R1’s IPP states, R1’s foot needs to be monitored frequently because it gets infected and spread quickly because of the wear from R1’s brace.

Based on a review of R1’s after visit Summary, dated February 19, 2024- February 20, 2024, R1 was diagnosed with a pressure ulcer, most likely due to R1’s leg braces.

Based on a review of R1’s Post-Discharge Plan dated November 14, 2023, R1’s visiting Nurse is provided by Best HH. The form also notes nursing Needs as: wound care and colostomy care.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation of neglect may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Page 4 Out of 4. END OF REPORT.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
03/12/2024 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20240312154828

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:
11/14/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:TIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff did not develop a restricted health conditions plan for a resident upon admission to the facility.
INVESTIGATION FINDINGS:
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On March 12, 2024, the Department received a complaint alleging staff did not develop a restricted health conditions plan for a resident upon admission to the facility.

On March 14, 2024, LPA Simi Rai interviewed ADM. ADM stated resident R1 was admitted to the facility on August 1, 2023. ADM stated when R1 moved to the facility, there was no wound on the foot. ADM stated R1 was living independently prior to moving to the facility, with a home health nurse for his/her catheter.

Page 1 Out of 2.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20240312154828
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: 11/14/2024
NARRATIVE
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ADM stated R1 was admitted to the hospital, February 20, 2024, resident discharged back to the facility. ADM stated the doctor at the hospital stated the wound was superficial. ADM stated she didn't know what that meant but she still admitted the resident back to the facility. ADM stated he/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 did not document anything in the facility. ADM stated she didn't know she needed a care plan for the wound since he was receiving home health services, and the facility staff did not touch the wound.

On September 28, 2024, LPA Monter interviewed ADM. LPA asked if the facility developed a restricted health conditions plan for R1’s catheter or R1's pressure wound. ADM stated she did not know a restricted health plan was required.

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.

The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with ADM Canonizado, via phone call. ADM stated Lead Staff Robert Foranda could sign on her behalf. A signed copy of this report was provided along with appeal rights.
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
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20240312154828
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: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2024
Section Cited
CCR
80092.2(a)
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80092.2 Restricted Health Condition Care Plan (a) If the licensee of an ARF chooses to care for a client with a restricted health condition …the licensee shall develop and maintain…a written Restricted Health Condition Care Plan…
The requirement was not met as evidenced by;
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ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send the written letter by POC date, November 15, 2024.
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Based on records review and interviews conducted, the facility did not create a restricted health plan for resident R1. ADM admitted she did not create a restricted health plan for R1’s catheter and pressure wounds. This poses an immediate health, safety, personal rights risks 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7