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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202168
Report Date: 11/22/2021
Date Signed: 11/22/2021 06:04:06 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2021 and conducted by Evaluator Steve Nguyen
COMPLAINT CONTROL NUMBER: 26-AS-20210513161843
FACILITY NAME:EVERGREEN GUEST HOME #4FACILITY NUMBER:
435202168
ADMINISTRATOR:JULIUS CANONIZADOFACILITY TYPE:
735
ADDRESS:4062 MC LAUGHLIN AVE.TELEPHONE:
(408) 365-9285
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:6CENSUS: 6DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Francisco Matias,TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility did not report residents' injury
Resident's hygiene needs are not being met
Facility has bed bugs
Staff did not seek medical attention for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Nguyen arrived unannounced to deliver the complaint investigation finding. LPA met with Staff Francisco Matias, and explained the purpose of the visit.

On 05/13/2021 the Department received a complaint regarding the above allegations.

On 05/20/2021 LPA Marybeth Donovan, opened the unannounced 10-day Complaint investigation and advised the Administrator that the Department would be conducting the investigation.

Between 05/17/2021 and 05/20/2021, the Department: interviewed the Administrator, 4 staff and 2 residents. Records reviewed includes but are not limited to: physician's report, appraisal needs and services plan, Individual Program Plan (IPP) and hospital records.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20210513161843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: EVERGREEN GUEST HOME #4
FACILITY NUMBER: 435202168
VISIT DATE: 11/22/2021
NARRATIVE
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5 out of 5 staff denied all allegations: all stated that injury or medical concern were reported, and care were provided promptly but some medical services was limited due to covid. Residents’ hygienic needs are met by staff; daily showers, help with toiletry are provided as needed throughout the day. None of the staff reported seeing any bed bugs within the facility. Facility was sprayed on 5/07/2021 as a preventive measure. A review of records indicated that resident was seen via VMC on 5/12/2021 and 5/14/2021 for rash and injured toe.

Resident 1stated that his/her needs are met and have no complaints. Resident 2 stated that he/she was fine, could not focus and did not participate with further questions.

Based on information from interviews conducted and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22.

This report was reviewed with Staff, Francisco Matias, and a copy of this report provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2