<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201385
Report Date: 12/27/2024
Date Signed: 12/27/2024 01:52:11 PM

Document Has Been Signed on 12/27/2024 01:52 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 ADULT DEVELOPMENT CENTERFACILITY NUMBER:
435201385
ADMINISTRATOR/
DIRECTOR:		CAROLINE C. MAYOFACILITY TYPE:
775
ADDRESS:2887 MCLAUGHLIN AVENUE,BLDG. ATELEPHONE:
(408) 578-1280
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 216CENSUS: 74DATE:
12/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Administrator Caroline MayoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management-incident regarding an incident which occurred where client (C1) eloped while attending the day program community outing activity. LPA Monter met with Administrator Caroline Mayo(ADM) and stated the purpose of today's visit.

On December 13, 2024, the Department received an incident report (IR) stating on December 13, 2024, client C1 had eloped from during a day program outing at a local mall. The IR states, On Friday, December 13, 2024, at approximately 11:30 AM, had just finished eating his/her meal when he asked his/her staff if he/she could stroll around the mall. His/her staff told C1 that the other clients in his/her group were still eating their meals, and asked C1 if he/she could wait until they were done. C1 agreed and sat behind his/her staff. After a few minutes, the staff turned around to find that C1 was not there. The staff immediately searched the food court and the bathroom; when he/she didn’t see C1 and told other staff to help find C1.

At 11:45 AM, staff called the Program Manager to inform them of the situation. The Assistant Program Director was informed, and they suggested calling campus security, which they did. One staff member went with security to look over the camera footage, a few staff secured the individuals, and the rest continued to search for C1.

At 11:57 AM, C1’s family member was called to inform him/her that C1 was missing at the mall. He/She told the PM and Assistant Program Director that he/she would meet them at the mall. C1 was found around 12:05 PM on the first floor in front of the Macy's store by a staff member.

Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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 3
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 ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 435201385
VISIT DATE: 12/27/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On December 27, 2024, Licensing Program Analyst Manuel Monter interviewed Staff S1-S4. Staff S1 stated he/she was in charge of C1 the day C1 had eloped from his/her group. S1 stated C1 told him/her that he/she wanted to roam around the mall. S1 stated he/she told C1 to wait. S1 stated C1 had sneaked out. S1 stated it took him/her 1-2 minutes to notice C1 had eloped from his group. S1 stated C1 came to the mall with a wheel chair and when C1 had eloped, C1 used his/her wheel chair as well.

Staff S2 stated he/she was walking her 1 on 1 client, C2, around the mall when C1 had eloped from his/her group. S2 stated he/she had left S1 and S3 to walk his/her 1 on 1 client and returned to the group about 10 minutes later. S2 stated that is when they informed him/her that C1 had gone missing.

Staff S3 stated around 11:30, C1 sat two tables away from staff S1 and S3 because C1 wanted to be alone. S3 stated S1 told C1 to wait to till S2 and C2 returned. S3 it was 5-7 minutes, the last moment he/she saw C1. S3 stated by the time S2 had returned with C2, that is when they realized that C1 was gone.

Staff S4 stated he/she was walking his/her 1 on 1 client in the mall. S4 stated he/she was informed that C1 was missing via text message and was not actually present when C1 had eloped.

Based on a review of C1’s Appraisal/Needs & Services (ANS)plan, dated October 7, 2024, C1 has a tendency to leave his/her group without notifying anyone. The ANS states under objective/plan, “staff will provide direct supervision with C1 when out in the community.”

Based on a review of C1’s Individual Program Plan, dated March 5, 2024, under safety skills/disaster preparedness, C1 has a tendency to leave others side without notifying them. C1’s teacher has mentioned a time when C1 left the group while at the mall without notifying staff. Under Health/Fitness/Nutrition, the form states C1 has a neurocognitive disorder with behavioral disturbance.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, wherein C1 eloped during a day program outing at a local mall on 12/13/2024 unsupervised.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Caroline Mayo. Appeal rights were provided.
Page 2 Out of 2. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/27/2024 01:52 PM - It Cannot Be Edited


Created By: Manuel Monter On 12/27/2024 at 12:54 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 ADULT DEVELOPMENT CENTER
FACILITY NUMBER: 435201385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2024
Section Cited
CCR
82078(a)

1
2
3
4
5
6
7
82078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator stated she will submit a written plan of action understanding regulation and staff Inservice training to ensure clients are provided care and supervision necessary to meet the client's needs
8
9
10
11
12
13
14
Based on interview and record review, facility staff did not provide the care and supervision wherein C1 eloped during a day program outing at a local mall on 12/13/2024 unsupervised which poses/posed an immediate Health, Safety or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
ADM stated POC will be submited by POC date, December 28, 2024.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3