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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201385
Report Date: 03/30/2026
Date Signed: 03/30/2026 12:57:00 PM

Document Has Been Signed on 03/30/2026 12:57 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: DATE:
03/30/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Administrator Caroline MayoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management-incident regarding an incident Resident R1 sustained an injury during transport. LPA Monter met with Administrator Caroline Mayo and stated the purpose of today's visit.

On March 27, 2026, the Department received an incident report, regarding resident R1, which stated the following. On 03/27/2026 at approximately 9:06 AM at Ruby Avenue San Jose CA 95148 while picking up R1, Staff S1 called the Administrative Assistant to report that R1 while in his/her wheelchair fell backward during transit.
At 9:08 AM: Program Manager called 911 as it was observed that R1 had sustained what appeared to be a cut to the back of his/her head and was bleeding.
At 9:45 AM: R1 was transported into the Regional Center Hospital by the Paramedics
At 11 AM: S1 returned to the day program where he/she was interviewed by Office Administration concerning his/her procedure securing R1 to the tie down. The Transportation Coordinator investigated the tie downs in the van and they were fully functional.

At 12:58 PM, Program Manager received an update from Care Home Admin and R1’s Family member who reported that R1 is at Regional Hospital, is being treated, the situation is stable and R1 is now resting. Care Home Admin reported that R1 had 7 stitches on the back of his/her head. The team is waiting for the MRI result.
At 2:47PM Care Home Admin called Program Manager that R1 was discharged from Regional and will be sending documents.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2026
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: 03/30/2026
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On March 27, 2026, Licensing Program Analyst Marcella Tarin interviewed ADM Caroline Mayo. ADM states the facility did an investigation led by Transportation Coordinator. ADM states the investigation found that S1 only did 3 ties down, instead of 4 tie downs on R1's wheelchair. ADM states there were no malfunctions with tie downs.

On March 30, 2026, Licensing Program Analyst Manuel Monter interviewed Staff S1. S1 stated on March 27, 2026, he/she had made a mistake during transport. S1 stated he/she did not properly secure R1's wheel chair. S1 stated he/she had only secured R1's wheel chair in 3 Out of 4 points. S1 stated he/she couldn't secure the fourth point because R2's wheel chair and R1's wheel chair did not leave enough room to allow him/her to secure R1.

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.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2026 12:57 PM - It Cannot Be Edited


Created By: Manuel Monter On 03/30/2026 at 12:23 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: 03/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2026
Section Cited
CCR
82065(a)

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82065 Personnel Requirements(a) Program personnel shall be competent to provide the services necessary to meet individual client needs ... necessary to meet such needs.
This requirement was not met as evidenced by:
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ADM stated staff S1 was terminated. ADM stated the facility will be conducting an in-service training on the proper use and demonstration of the 4 point wheel chair tie down system.
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Based on interviews and records reviewed, on March 27, 2026, resident R1 sustained a fall during transport. Staff S1 admitted he/she did not fasten R1's wheel chair all 4 wheelchair tie downs. This poses an immediate Health, Safety or Personal Rights risk to persons in care.
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ADM stated she will send documentation the training has taken place to LPA by POC due date, March 31, 2026.

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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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2026


LIC809 (FAS) - (06/04)
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