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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201385
Report Date: 05/08/2024
Date Signed: 05/08/2024 12:21:56 PM

Document Has Been Signed on 05/08/2024 12:21 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: 64DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:58 AM
MET WITH:Administrator Caroline C. MayoTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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On April 10, 2024, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management-Incident visit regarding an incident report on May 7, 2024. LPA met with Administrator Caroline C. Mayo and explained the purpose of the visit.

On May 7, 2024, the Department received an incident report alleging a staff member sexually abused a resident. It has been alleged a staff member placed his/her private parts on a client.

On May 8, 2024, LPA Monter interviewed staff S1. S1 denied doing anything inappropriate to client C1. S1 stated C1 takes a taxi home to and from the day program. S1 stated he/she is also a 1 on 1 staff for client C2. S1 stated he/she does not interact with C1.

LPA interview C1. C1 stated he/she was not sexually abused. C1 stated staff member S1 brushed up against him/her when he/she is drawing. C1 stated he/she doesn't like when male staff get close or touch him/her.

LPA interviewed C1's Conservator (CC). CC stated C1 re-enacted the alleged abuse to show CC what occurred at the day program. CC stated based on the re-enactment, a staff member brushed up against C1 when he/she was drawing.

The Department has completed the investigation of the sexual abuse. Based on interviews conducted, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited, an exit interview conducted with Administrator, Administrator Caroline C. Mayo and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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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