430707505-8-8-2025-26-AS-RMAO-DKVPJC-20250825112118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430707505
Report Date: 08/08/2025
Date Signed: 08/08/2025 05:43:38 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
06/17/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20250617164444

FACILITY NAME:	EVERGREEN GUEST HOME #2		FACILITY NUMBER:	430707505
ADMINISTRATOR:	CANONIZADO, E. & F.		FACILITY TYPE:	735
ADDRESS:	1628 MCLAUGHLIN AVENUE		TELEPHONE:	(408) 286-5985
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95122
CAPACITY:	6	CENSUS: 6	DATE:	08/08/2025
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Administrator Evelyn Canonizado		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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Facility has a foul sewage odor
Facility water temperature is not maintained between 105 °F and 120 °F.
Facility meals do not meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan
Staff do not ensure that rooms residents occupy are maintained between 68 °F and 85 °F

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced investigation visit to deliver the investigation finding and met with Staff S4 and S5. LPA spoke with ADM via phone call. ADM stated Staff Lolita Ignacio could sign on her behalf.

On June 17, 2025, the Department received a complaint alleging Facility has a foul sewage odor.

On June 25, 2025, LPA Manuel Monter interviewed residents R2-R6. R2 stated sometimes the home has a bad smell. R2 stated he/she doesn’t know why it smells bad sometimes. R3 stated he/she doesn’t remember smelling any foul or bad odors in the facility.

3 Out of 6 residents (R4-R6) interviewed were unable to provide answers to LPA's questions. Residents interviewed had behaviors such as not talking or engaging in other actions such as playing with toy/eating etc.
Page 1 Out of 6.

Unsubstantiated

Estimated Days of Completion:

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

LIC9099 (FAS) - (06/04)

Page: 1 of 12

Control Number 26-AS-20250617164444

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: 08/08/2025

NARRATIVE

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LPA interviewed staff S1-S3. S1 stated he/she lives in the facility as the live in staff and there isn’t any foul odor in the facility. Staff S2 and S3 stated they have not smelled any foul odor in the facility.

LPA interviewed ADM. ADM stated the facility doesn’t have any foul odor.

On July 16, 2025, LPA Monter Interviewed R1. R1 stated his/her room smells because after someone went to the bathroom, it smelled. R1 stated they didn’t clean the bathroom well. R1 stated this happened a few months ago. R1 stated it hasn’t smelled bad recently.

Licensing Program Analyst Manuel Monter conducted multiple visits at the facility and toured the following dates: June 25, July 15-16, July 18-19, August 8, 2025. LPA did not note any foul smells in the facility.

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 may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Staff do not ensure that rooms residents occupy are maintained between 68 °F and 85 °F

On June 17, 2025, the Department received a complaint alleging Staff do not ensure that rooms residents occupy are maintained between 68 °F and 85 °F.

On June 25, 2025, LPA Manuel Monter interviewed residents R2-R6. R2 stated there has been times when the facility gets hot. R3 stated the room temperature at the facility is ok.

R2 stated when it gets hot in the facility, the staff close the blinds and turn on the fan. R2 stated the staff also gives the residents cold water. R3 stated when the home does get hot, the staff gives residents waters and turn on the fans.

3 Out of 6 residents (R4-R6) interviewed were unable to provide answers to LPA's questions. Residents had behaviors such as not talking or engaging in other actions such as playing with toy/eating etc.
Page 2 Out of 6

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

LIC9099 (FAS) - (06/04)

Page: 2 of 12

Control Number 26-AS-20250617164444

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: 08/08/2025

NARRATIVE

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LPA interviewed staff S1-S3. S1 stated the inside temperature of the facility is comfortable. S1 stated when its hot, the staff gives them water and turns on fans. S2 stated the facility’s air temperature is comfortable. S2 stated they have air conditioning. S2 stated when it gets hot, they turn on the AC, give water to residents. S3 stated the water at the facility isn’t too hot or too cold. S3 stated the water is at a comfortable temperature.

LPA interviewed ADM. ADM stated the facility doesn’t get hot. ADM stated they maintain the facility temperature between 68 °F and 85 °F.

On July 16, 2025, LPA Monter interviewed R1. R1 stated his room does get hot sometimes, but now that the fan in his room is fixed, its not hot anymore.

Licensing Program Analyst Manuel Monter conducted multiple visits at the facility and measured the facility’s indoor room temperature, using a thermometer, for the following dates: June 25, July 15-16, July 18-19, 2025, & August 8,2025. The facility indoor room temperature measured at a range of 75-82 degrees F.

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 may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Facility water temperature is not maintained between 105 °F and 120 °F.

On June 17, 2025, the Department received a complaint alleging Facility water temperature is not maintained between 105 °F and 120 °F.

On June 25, 2025, LPA Manuel Monter interviewed residents R2-R6. R2 stated the water temperature is ok. R2 stated the water is not too hot or too cold. R3 stated the water temperature at the facility is cold. R3 stated this happens sometimes when he/she takes showers in the morning. R3 stated the water at the facility does get hot sometimes too. Page 3 Out of 6

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

LIC9099 (FAS) - (06/04)

Page: 3 of 12

Control Number 26-AS-20250617164444

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: 08/08/2025

NARRATIVE

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3 Out of 6 residents (R4-R6) interviewed were unable to provide answers to LPA's questions. Residents interviewed had behaviors such as not talking,or engaging in other actions such as playing with toy/eating etc.

LPA interviewed staff S1-S3. S1 stated the facility water temperature is good. S1 stated he checks the temperature once a week and its Usually 110 degrees. S2 and S3 stated the water temperature is at a comfortable temperature.

LPA interviewed ADM. ADM stated the facility water temperature is set between 105 °F and 120 °F

On July 16, 2025, LPA Monter Interviewed R1. R1 stated he/she told to his/her family member that the water was too cold in the beginning of June. R1 stated after he/she told his/her family member, they fixed it. R1 stated the water is no longer cold.

Licensing Program Analyst Manuel Monter conducted multiple visits at the facility and measured the facility’s water temperature, using a thermometer, for the following dates: June 25, July 15-16, July 18-19, 2025 and August 8, 2025. The facility water temperature measured at a range of 107-113 degrees F.

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 may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Facility meals do not meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan

On June 17, 2025, the Department received a complaint alleging Facility meals do not meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan.

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

LIC9099 (FAS) - (06/04)

Page: 8 of 12

Control Number 26-AS-20250617164444

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: 08/08/2025

NARRATIVE

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On June 25, 2025, LPA Manuel Monter interviewed residents R2-R6. R2 stated his/her food tastes good and he/she’s happy with his/her food. R3 stated the facility provides lots of different kinds of meals for residents. R3 stated the staff makes the following types of food: apples, noodles, sandwiches, watermelon, chicken, rice.

3 Out of 6 residents (R4-R6) interviewed were unable to provide answers to LPA's questions. Residents interviewed had behaviors such as not talking, or engaging in other actions such as playing with toy/eating etc.

LPA interviewed staff S1-S3. S1 and S2 stated they are the staff who cook at the facility. S1 stated the home makes soup, vegetables, broccoli, Carrots, chicken, and rice. S2 stated the facility makes the following food for the residents: chicken, vegetables, mashed potatoes, sausage. S2 stated they don’t make the same food for the residents every day. S2 stated they also make sandwiches, salads, bologna, and ham for the residents. S3 stated he/she doesn’t cook. S3 stated the facility makes R5’s favorite foods that the father told them. S3 stated ramen and cheese is R5’s favorite food. S3 stated the home does not make the same meals everyday. S3 stated the home makes sandwiches, fruits, vegetables, soups, rice, chicken, yogurt.

LPA interviewed ADM. ADM stated the facility has a Menu. ADM stated the facility makes food that has food that includes fiber, protein, fruits and vegetables.

On June 25, 2025, LPA Monter reviewed the facility food supply, which included the following, but not limited to food: bread, pepperoni pizza, macaroni & cheese, pasta, noodles, yogurt, chicken, milk, apples, assorted vegetables, refried beans, tomato Sauce, Oatmeal, rice, potatoes, sausage, tomatoes, lettuce, cheese, cereal, pears, tuna, green beans, breaded chicken, ham, eggs, cucumbers, and pineapples.

On July 16, 2025, LPA Monter Interviewed R1. R1 stated he/she gets 3 meals a day. R1 stated in the morning he/she is given eggs and milk. R1 stated he/she doesn’t like bread. R1 stated his/her lunch is usually rice, and the food that his/her family member brings him/her. R1 stated staff might add cucumbers, or a boiled potato or chicken. R1 stated he/she likes the rice.

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

LIC9099 (FAS) - (06/04)

Page: 7 of 12

Control Number 26-AS-20250617164444

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: 08/08/2025

NARRATIVE

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On August 8, 2025, LPA Monter observed staff serve residents dinner: vegetable-chicken soup, with grapes or apples for the residents.

LPA Monter conducted multiple visits at the facility to observe the meals that were provided to residents. On July 15, 2025, LPA observed residents lunch included: ham sandwich, cookie, applesauce, fruit juice, tortilla chips, rice, chicken, cucumbers, and an apple. On July 16, 2025, LPA observed residents lunch included: rice, guava, fruit, beef, green beans/spinach, tortilla chips, apple sauce, gram crackers, turkey sandwich, and an apple. On July 18, 2025, LPA observed residents lunch included: ham sandwich, apples, gram crackers, beef, rice, cucumbers, tortilla chips, and an apple.

LPA reviewed a copy of Evergreen Guest home #2's grocery receipts for the months of May, June & July 2025. LPA observed a variety of food such as, but not limited to: whole milk, carrots, pasta, honey Graham's, French fires, tortilla chips, hot-dogs, ham, franks, brocoli, eggs, chicken, rice, biscuits, cheerios, cabbage, burritos, Quaker oats, apples, potatoes, milk, cereal, celery, tomatoes, mangos, squash, blueberries, beef, beans, papaya, melon, avocado.

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 may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

Page 6 Out of 6. END OF REPORT.

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

LIC9099 (FAS) - (06/04)

Page: 6 of 12

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
06/17/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20250617164444

FACILITY NAME:	EVERGREEN GUEST HOME #2		FACILITY NUMBER:	430707505
ADMINISTRATOR:	CANONIZADO, E. & F.		FACILITY TYPE:	735
ADDRESS:	1628 MCLAUGHLIN AVENUE		TELEPHONE:	(408) 286-5985
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95122
CAPACITY:	6	CENSUS: 6	DATE:	08/08/2025
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Administrator Evelyn Canonizado		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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Facility does not offer residents with activities

INVESTIGATION FINDINGS:

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On June 17, 2025, the Department received a complaint alleging Facility does not offer residents with activities.

On June 25, 2025, LPA Manuel Monter interviewed residents R2-R6. R2 stated the home doesn’t have any activities. R2 stated the only thing they do is watch TV. R2 stated the home does not have any outings. LPA asked R2 if the facility asks him/her what activities he/she would like to do. R2 stated no. R3 stated the only activities the home has is puzzles and sometimes going to the mall. R3 stated the home has no other activities. LPA asked R3 if the facility asked him/her what activities he/she would like to do. R3 stated no.

3 Out of 6 residents (R4-R6) interviewed were unable to provide answers to LPA's questions. Residents interviewed had behaviors such as not talking, or engaging in other actions such as playing with toy/eating etc. Page 1 Out of 3.

Substantiated

Estimated Days of Completion:

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

LIC9099 (FAS) - (06/04)

Page: 9 of 12

Control Number 26-AS-20250617164444

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: 08/08/2025

NARRATIVE

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LPA interviewed staff S1-S3. S1 stated regarding facility activities: they go to the park, got to the mall on the weekends. S1 stated the residents play basketball in the backyard or play with puzzles. 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.

S2 stated the facility does have activities, such as basketball, drawing/coloring, walking, going to the park. S2 stated she doesn’t join them in the activities. S3 stated he/she is the 1 on 1 staff for resident R5. S3 stated he/she mainly works with R5. S3 stated he/she walks with R5 to either the park or the mall. S3 stated he/she walks him/her everyday. S3 stated that’s the activity he/she does with R5.

LPA interviewed ADM. ADM stated residents go out to the park. ADM stated the residents choose their activities which include; playing basket ball in the backyard, watching television, or puzzles.

During visit conducted on June 25, 2025, from 2:20pm - 4:45pm, LPA did not observe any activities/ or suggestion of activities with residents in care.

On July 16, 2025, LPA Monter Interviewed R1. R1 stated they don’t do any activities at the facility. R1 stated he/she was told by staff he/she can’t watch television because it uses a lot of power. R1 stated there is nothing to do at the home. R1 stated the facility doesn't ask him what activities he/she wants to do.

On August 8, 2025, LPA interview S4 and S5 stated between 1:45pm-2:00pm. LPA asked S4 and S5 what planned activities were scheduled for today. S4 stated the residents can play basketball outside or walk around the house. S5 stated the residents can watch television. LPA Monter did not observe any activities/ or suggestion of activities with residents in care. LPA asked S4 and S5 if they could provide the weekly activity calendar. LPA was not provided this weeks activity calendar.

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

LIC9099 (FAS) - (06/04)

Page: 10 of 12

Control Number 26-AS-20250617164444

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: 08/08/2025

NARRATIVE

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The Department reviewed R4’s Progress Notes dated April 1, -July 4, 2025. Based on a review, R4 did the activity, “walking in the backyard/walking in the house” for the following dates: 4/1, 4/5, 4/6, 4/9, 4/10, 4/14, 4/15, 4/16, 4/20, 4/21, 4/23, 4/24, 4/27, 4/29, 5/2, 5/3, 5/5, 5/7, 5/10, 5/12, 5/17, 5/29, 6/1, 6/15, 6/17, 6/18, 6/20, 6/28, 6/29.

The Department reviewed R1’s Progress Notes dated March 31, - July 7, 2025. Based on a review R1 did the activity, “walking in the back yard/walking in the house” for the following dates: 4/14, 4/17, 4/20, 4/26, 4/30, 5/4, 6/15, 6/24, 6/30, 7/6.

Furthermore, the following dates have no activities listed on R1’s Progress Notes: 5/2/25.

The Department reviewed facility Weekly activities calendar for the dates: July 7-July 13, June 30-July 6, and July 28-Aug 3, 2025. Based on a review, activities are scheduled from 3:00pm-4:00pm, Monday thru Saturday. Activites on Sunday are scheduled from 10:00am-11:00am.

On June 25, 2025 and August 8, 2025, LPA was present at the facility between 3:00pm and 4:00pm. LPA did not observe any activities/ or suggestion of activities with residents in care.

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-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. END OF REPORT.

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

LIC9099 (FAS) - (06/04)

Page: 11 of 12

Control Number 26-AS-20250617164444

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: 08/08/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/15/2025 Section Cited CCR 85079(a)(1)(2)	1 2 3 4 5 6 7	85079 Activities (a) The licensee shall ensure that planned recreational activities...are provided for the clients... require group interaction...but not limited to games, sports and exercise. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	ADM stated she will submit a written plan of action detailing how she will ensure there are planned recreational activities that include group interaction, physical activites. ADM stated she will also ensure residents are given the opportunity to participate in the planning, preparation.
	8 9 10 11 12 13 14	Based on records reviewed the facility did not provide planned activities in multiple instances.On June 25, 2025 and August 8, 2025 LPA did not observe any activities conducted for residents in care. This poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	ADM stated she will submit this written plan of action to LPA by POC date, August 15, 2025.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: 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

LIC9099 (FAS) - (06/04)

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