435201385-3-10-2026-26-AS-MMOR-DS2RAJ-20260310125112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201385
Report Date: 03/10/2026
Date Signed: 03/10/2026 12:51:22 PM

Document Has Been Signed on 03/10/2026 12:51 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 CENTER		FACILITY NUMBER:	435201385
ADMINISTRATOR/ DIRECTOR:	CAROLINE C. MAYO		FACILITY TYPE:	775
ADDRESS:	2887 MCLAUGHLIN AVENUE,BLDG. A		TELEPHONE:	(408) 578-1280
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY: 216		CENSUS: 88	DATE:	03/10/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:55 AM
MET WITH:	Assistant Program Director Tiana Musika		TIME VISIT/ INSPECTION COMPLETED:	01:00 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	On March 10, 2026 Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management-incident regarding an incident where a residents medication was not found. LPA Monter met with Assistant Program Director (APD) Tiana Musika and stated the purpose of today's visit. On March 3, 2026, the Department received an incident report, regarding resident R1, which stated the following. On February 27, 2026 at approximately 9:10 AM, staff reported that R1’s medication (M1) was not found in R1’s backpack. At 9:12 AM, Program Manager contacted R1’s family member, by phone to notify him/her of the missing medication and left a voicemail message. Update on March 3, 2026, medication M1 has not been located. On March 4, 2026, LPA Mita Partoza spoke to APD. APD stated that they take the medication out of the backpack and place the medication inside a lock box, then taken out at the end of the day and placed back in the front pocket of participant's backpack. APD stated that on Wednesday afternoon, they did not find the medication in the lock box. APD stated that the participant has a 1 on 1 caregiver and helps out with placing the medication in the lock box. APD stated that he/she was not sure what happened in the afternoon of Wednesday. APD stated based on the conversation, staff stated that on Thursday morning, the 1 on 1 of the participant did not see the medication, and thought that one of the staff have already put the medication in the lock box. The 1 on 1 care giver did not confirm with the staff if the medication was in the lock box. The medication according to the staff has been missing since Wednesday afternoon. Page 1 Out of 2.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

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 ADULT DEVELOPMENT CENTER	FACILITY NUMBER: 435201385
	VISIT DATE: 03/10/2026

NARRATIVE

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On March 10, 2026, LPA spoke with APD. APD stated, R1's family member informed the facility that he/she hasn't touched R1's medication and 3 weeks ago was the last time he/she interacted with the back pack containing the medication.

APD stated Thursday morning, facility staff did not check R1's backpack to confirm if the medication was secured in the secured lock box. APD stated it was discovered that R1's Medication M1 was not found in either the lockbox or R1's back pack.

LPA interviewed Staff S1 and S2. S1 stated on February 27, 2026, he/she has assumed Staff S2 had taken out R1's M1. S1 stated when he/she starts his/her shift, he/she will take out the M1 and give it to S2 or S2 will take out the M1. S1 stated when she has seen the backpack was missing the M1, he/she assumed S2 had taken the M1 out.

Staff S2 stated he/she was busy that morning and did not check R1's backpack for M1. S2 stated he/she was busy and did not get the opportunity to check.

The Department reviewed R1’s Care Plan, dated November 3, 2025. The care plan states R1’s M1 will be readily available at all times. Staff will check and make sure R1’s M1 is with him/her upon arrival. Staff will assist R1 with the administration of M1.

The Department Reviewed R1’s Physician’s Report, dated October 6, 2025. Based on a review, R1 cannot administer his/her own medication.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Assistant Program Director Tiana Musika. 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: 03/10/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/10/2026 12:51 PM - It Cannot Be Edited

Created By: Manuel Monter On 03/10/2026 at 12:17 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: 03/10/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/17/2026 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 was not met as evidenced by:	1 2 3 4 5 6 7	ADP stated staff training will be provided this Friday, March 13, 2026, regarding medication arrival. ADP stated she will send LPA documentation by POC due date, March 17, 2026.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, R1's care plan states Staff will check and make sure R1’s M1 is with him/her upon arrival. ADP stated staff did not check to ensure R1's M1 was with him/her when he/she arrived.	8 9 10 11 12 13 14	This poses a potential Health, Safety or Personal Rights risk to persons in care.
	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.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

LIC809 (FAS) - (06/04)

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