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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707505
Report Date: 05/24/2024
Date Signed: 05/24/2024 11:39:04 AM

Document Has Been Signed on 05/24/2024 11:39 AM - 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:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Administrator EVELYN CANONIZADOTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPAs) Manuel Monter and Mita Partoza conducted an unannounced annual inspection visit, and met with staff S1, Lolita Ignacio. S1 contacted facility ADM, and ADM stated she would be able to be at the facility by 11am. During the visit, LPA observed 2 residents and 2 staff.

When LPA's entered the home, Staff S1 was updating the Medication Administration Record, Staff S2 is the 1 on 1 care giver for R4 and was accompanying R4 in his/her bedroom. Staff S3 was in his/her bedroom because it is his/her day off.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 3 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the facility Laundry room, LPA's observed a container of detergent accessible to residents in care. (Photographs were taken.)

While touring facility bathroom adjacent to bedroom #6, LPA was informed by staff S1 and S3, that the toilet is clogged. S1 stated the toilet has been clogged since Monday. S3 stated the toilet has been clogged since Wednesday. ADM stated the plumber is scheduled to come to the facility on 5/25/2024. ADM stated she would send LPA a copy of the receipt.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured to range from 111-112 degrees F in resident bathrooms.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 05/24/2024 11:39 AM - It Cannot Be Edited


Created By: Manuel Monter On 05/24/2024 at 11:04 AM
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: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)(E)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: (E) The prescription number and the name of the issuing pharmacy.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. While reviewing resident R4's medications, LPA observed two medication's prescription numbers did not match with the centrally stored medication log. S3 stated he/she is the one filled out the log and stated he/she does not know where he/she got the incorrect prescription numbers. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure the maintenance of a record of centrally stored prescription medications. ADM stated she will send the written plan of action by POC date, 5/31/2024.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The facility's last drill was on October 15, 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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ADM stated she will conduct a fire/earthquake drill and send LPA documentation that a drill has taken place. ADM stated she will send the documentation by POC date, May 31, 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: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/24/2024 11:39 AM - It Cannot Be Edited


Created By: Manuel Monter On 05/24/2024 at 11:05 AM
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: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. While touring the facility Laundry room, LPA's observed a container of detergent accessible to residents in care. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger are inaccessible to clients. ADM stated she will send the written plan of action to LPA by POC date, 5/31/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 05/24/2024
NARRATIVE
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Fire extinguisher was serviced in September 22, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 15, 2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA's reviewed 3 residents P&I records. LPA reviewed 3 resident medications and centrally stored medication records. While reviewing resident R4's medications, LPA observed two medication's prescription numbers did not match with the centrally stored medication log. S3 stated he/she is the one filled out the log and stated he/she does not know where he/she got the incorrect prescription numbers. LPA conducted interviews with 2 staff and 1 residents.

Deficiencies are being cited during today's visit. This report was reviewed with Administrator CANONIZADO and a copy of the signed report was provided. Appeal rights were provided.

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END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4