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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202168
Report Date: 04/16/2025
Date Signed: 04/16/2025 02:59:35 PM

Substantiated


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
02/25/2025 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20250225190311

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:
04/16/2025
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:StaffTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Facility is not meeting the hygiene needs of residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Staff Maribel Dadacay. ADM was informed about LPA's visit via phone call.

On February 25, 2025, the Department received a complaint alleging the facility is not meeting the hygiene needs of residents in care. It has been alleged that resident R1 was observed with poor dental hygiene and wearing 2 diapers.

On March 6, 2025, LPA interviewed Witness W1. W1 stated he/she observed resident R1 with poor dental hygiene. W1 stated he/she doesn’t know if the facility is washing R1’s teeth. W1 stated he/she observed R1 wearing 2 diapers.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20250225190311
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: 04/16/2025
NARRATIVE
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On March 6, 2025, LPA Manuel Monter interviewed Staff S1-S3. Staff S1-S3 stated residents are checked/changed every 2 hours. S1 and S2 stated staff brush residents’ teeth every day; morning, after lunch and after dinner. S3 stated R1 will sometimes not want to have his/her teeth brush and is combative and will refuse. S3 stated staff tries to brush R1's teeth but can't force him/her.

S1 stated staff does put two diapers for residents to prevent the resident from being soaked at night. (LPA reiterated what staff S1 stated, then S1 recanted and stated staff doesn’t put residents in double diapers.) S1 stated the staff puts residents diaper then they put the pads in the residents bed to make sure the resident doesn’t soak. Staff S2 stated staff only puts one diaper on the residents. S2 stated the facility does put pads for R1. S3 stated he/she puts a double diaper on the resident during the evening, when residents are going to sleep. S3 stated he/she does this so the residents wont soak the bed at night.

LPA Monter interviewed residents R1-R4. Residents R1-R3 did not respond to LPA’s questions. 3 Out of 4 residents interviewed (R1-R3) ignored LPA and did not provide responses to LPA’s questions, while being distracted by television, radio and or ignored LPA. Resident R4 stated he/she declined to be interviewed and stated he/she preferred to go to sleep.

On April 14, 2025, LPA Monter interviewed R1's Service Coordinator (SC). SC stated he/she doesn’t know if R1 wears double diapers. SC stated he/she has no knowledge of residents wearing double diapers.

SC stated its hard to brush R1's teeth. SC stated R1 goes to the dentist once year. SC stated R1 needs sedation when he goes to his dentist appointments. SC stated R1 resists and doesn’t like it and bites whenever staff tries to brush his/her teeth. SC stated they might add this behavior to R1’s Individual Program Plan. SC stated A foreign object entering a residents mouth, its hard if the resident refuses or isn’t cooperating.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 26-AS-20250225190311
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: 04/16/2025
NARRATIVE
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On April 8th 2025, LPA interviewed Witness W2. W2 stated he/she has observed R1 with double diapers. W2 stated he/she has also observed one of the pads, inserted inside the diaper as well.

On April 16, 2025, LPA Monter interviewed facility Administrator. ADM stated he has no knowledge about staff putting 2 diapers on residents. ADM stated he has not observed staff placing or residents wearing double diapers. ADM stated regarding R1's oral hygiene, R1 has behavior, when in he/she has no control of his/her mouth. ADM stated R1’s behaviors make it more difficult to brush his/her teeth.

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with facility administrator via phone call. ADM granted staff Staff Maribel Dadacay to sign on his behalf. And a copy of the report was provided. Appeal Rights was provided.

Page 3 Out of 3. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20250225190311
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2025
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a) ...each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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 conduct a personal rights training regarding, personal rights and the use of 2 diapers.
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Based on interviews conducted, Staff S2 admitted he/she was double diapering residents in care. Witness W1 and W2 observed Resident R1 wearing 2 diapers at the same time. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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ADM stated he will send the plan of correction to LPA by POC date, April 17, 2025.
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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.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6