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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202168
Report Date: 04/12/2024
Date Signed: 04/12/2024 03:30:10 PM

Document Has Been Signed on 04/12/2024 03:30 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 GUEST HOME #4FACILITY NUMBER:
435202168
ADMINISTRATOR/
DIRECTOR:		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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator Julius Canonizado.TIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator (ADM) Julius Canonizado.

While investigating the complaint 26-AS-20220711133100, LPA reviewed R1’s Individual Program Plan (IPP), dated February 22, 2022. R1's IPP states, R1 is non-ambulatory and uses a manual wheelchair independently. The IPP states; R1 is observed to slide down on his seat during transport. Posey vest/gait belt need to ensure R1's safety/well-being. The form also states R1 is required to have a gait belt/poesy vest.

On July 15, 2022, the Department interviewed ADM. ADM stated R1 needs the chest harness because he/she doesn’t have control over his body.

On April 12, 2024, LPA interviewed ADM. ADM stated R1 is currently using his/her wheel chair. ADM stated R1's wheel chair has a chest strap and a lap belt.

Based on a facility file review, the facility does not have an exception for the postural support device.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Julius Canonizado. A copy of the report and appeal rights were provided.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2024 03:30 PM - It Cannot Be Edited


Created By: Manuel Monter On 04/12/2024 at 07:14 AM
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 GUEST HOME #4
FACILITY NUMBER: 435202168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2024
Section Cited
CCR
80072(a)(8)

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80072 Personal Rights (a)(8)Not to be placed in any restraining device. Postural supports may be used under the following conditions:

This requirement was not met as evidenced by;
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ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will also send an exception request for the postural supports for R1. ADM stated he will send the plan of correction by POC date, April 15, 2024.
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Based on record review and interviews conducted, the ADM stated he is using the lap belt and chest strap for R1, but does not have an exception for the restraining device. This poses an immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024


LIC809 (FAS) - (06/04)
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