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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430707505
Report Date: 04/17/2025
Date Signed: 04/17/2025 10:44:42 AM

Document Has Been Signed on 04/17/2025 10:44 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:
04/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Lead Staff Robert ForandaTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Lead Staff Robert Foranda S1. During the visit, LPA observed 2 residents and 2 staff. LPA explained the purpose of the visit. Staff S1 informed ADM of LPA's visit via phone call and text message.

LPA toured the facility inside out with staff S1 which included the Living room, kitchen, dining room, 3 restrooms and 4 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.

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 72 degrees F, and hot water temperature was measured at 108 degrees F in resident bathrooms.

Fire extinguisher was serviced in September 26, 2024. 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 April 15, 2025.

LPA reviewed facility records for 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records. LPA conducted interviews with 2 residents.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/17/2025
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Based on a review of resident R1's file, R1 has a Colostomy bag. A review of R1's physician's report, dated February 11, 2025, R1 is not capable of self care. Based on record review, the facility does not have an exception request for this restricted health condition.

LPA reviewed facility records for 3 staff. LPA requested to see staff S2's file. S1 confirmed that S2 does work at Evergreen guest home #2. S1 stated he/she could find the file to provide to LPA and to ask the ADM, who was not responding to phone calls/text messages from staff S1.

LPA Monter provided ADM with annual file review letter, stating there are forms or documents that need an update. LPA requested ADM send the following forms to LPA by April 24, 2025.

1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. Qualifications of Administrator (Certificate)
6. Please submit copy of surety bond

Deficiencies cited during today's visit. This report was reviewed with Lead Staff Robert Foranda and a copy of the signed report was provided. Appeal Rights were provided.

Page 2 Out of 2. END OF REPORT.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2025 10:44 AM - It Cannot Be Edited


Created By: Manuel Monter On 04/17/2025 at 10:30 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: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80092.4(a)(1)
Colostomy/Ileostomy
(a) A licensee of an adult CCF may accept or retain a client who has a colostomy or ileostomy if all of the following conditions are met: (1) The client is mentally and physically capable of providing all routine care for his/her ostomy, and the physician has documented that the ostomy is completely healed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. Based on a review of resident R1's file, R1 has a Colostomy bag. A review of R1's physician's report, dated February 11, 2025, R1 is not capable of self care. Based on record review, the facility does not have an exception request for this restricted health condition. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2025
Plan of Correction
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ADM stated she will send an exception request for R1's Colostomy. ADM stated she will send to LPA by POC date, April 24, 2025.
Type B
Section Cited
CCR
80066(c)
80066 Personnel Records (c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to see staff S2's file. S1 confirmed that S2 does work at Evergreen guest home #2. S1 stated he/she could find the file to provide to LPA and to ask the ADM, who was not responding to phone calls/text messages from staff S1. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2025
Plan of Correction
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ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send to LPA by POC date, April 24, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2025


LIC809 (FAS) - (06/04)
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