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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202168
Report Date: 04/12/2024
Date Signed: 04/12/2024 03:31:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
07/11/2022 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20220711133100
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: 5DATE:
04/12/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Julius Canonizado.TIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Resident not being provided adequate service.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegations listed above. LPA met with Administrator Julius Canonizado. LPA explained the purpose of the visit.

On July 11, 2022, the department received a complaint alleging a resident was not receiving adequate service, due to R1 being observed as unhygienic.

On July 15, 2022, LPA Maruffo interviewed staff S1-S3. 3 stated Out of 3 staff interviewed stated they shower the residents before they go to day program. S1 & S3 stated the facility washes the cloths every day because the resident’s soil themselves and need to be showered and changed.

Page 1 Out of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
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 4
Control Number 26-AS-20220711133100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GUEST HOME #4
FACILITY NUMBER: 435202168
VISIT DATE: 04/12/2024
NARRATIVE
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LPA Maruffo interviewed ADM. ADM stated the facility showers the residents at least once a day. ADM stated the facility will also shower and change the residents if they have an accident as well. ADM stated R1 has a behavior of putting his/her hand in his/her mouth. ADM stated the staff will re-direct the R1, but its an ongoing behavior. ADM stated the staff will clean up R1, after he/she puts his/her hands in his/her mouth, but the smell of saliva is going to be there.

LPA Maruffo made the following observations on July 15, 2022. LPA observed 6 out of 6 residents clothes as hygienic. LPA did not observe residents in disheveled or soiled state.

On December 12, 2023 and April 12, 2024, LPA Monter observed 4 residents at the facility, including R1. LPA did not observe residents in disheveled or soiled state.

Based on a review of R1's Individual Program Plan, dated, February 22, 2022, R1 has a behavior of frequently putting his/her hands in his/her mouth.

There is no sufficient evidence to prove or disprove the allegation that abuse, or assault occurred. The preponderance of the evidence gathered and analyzed indicated that the allegation is not true, therefore, the allegation is UNSUBSTANTIATED.

Page 2 Out of 2

END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4