<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202168
Report Date: 12/12/2023
Date Signed: 12/12/2023 03:17:10 PM

Document Has Been Signed on 12/12/2023 03:17 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:JULIUS CANONIZADOFACILITY TYPE:
735
ADDRESS:4062 MC LAUGHLIN AVE.TELEPHONE:
(408) 365-9285
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Administrator Julius CanonizadoTIME COMPLETED:
03:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Julius Canonizado . During visit, LPA observed 4 residents and 2 staff.

LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 117 degrees F in both resident bathrooms.

Fire extinguisher was serviced on September 22, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on November 15, 2023.

LPA reviewed facility records for 3 staff & 3 residents. LPA reviewed 3 resident medications & centrally stored medication records. LPA reviewed 3 resident LPA conducted interviews with 2 staff (S1-S2) & 3 residents (R1-R3). LPA randomly reviewed 3 resident P&I records with ADM. R5 was missing a dollar from his/her P&I funds, when referencing the P&I log. R2 p&i funds were 2 dollars over when referencing the P&I log. R4's P&I funds were $45 dollars over, when referencing the P&I funds. ADM stated, "i think i must of miscounted it or something."ADM stated he did not take the money out from a recent transaction and will fix it

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Julius Canonizado. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/12/2023 03:17 PM - It Cannot Be Edited


Created By: Manuel Monter On 12/12/2023 at 02:55 PM
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: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(14)
Client Records
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on a random review of resident P&I records, ADM and LPA observed discrepencies in 3 Out of 3 resident P&I records when cross referencing the funds and the P&I log. R5 was missing a dollar from his/her P&I funds. R2 p&i funds were 2 dollars over. R4's P&I funds were $45 dollars over. ADM stated, "i think i must of miscounted it or something." This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2023
Plan of Correction
1
2
3
4
ADM stated he will send a plan of action to LPA on how the facility will keep residents cash resource records information accurate, by POC date, December 19, 2023.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2