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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202168
Report Date: 07/30/2024
Date Signed: 07/30/2024 02:39:23 PM

Document Has Been Signed on 07/30/2024 02:39 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: 4DATE:
07/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Administrator Julius CanonizadoTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst Manuel Monter conducted an unannounced case management visit-Other pertaining to resident R1's postural support exception. LPA explained the purpose of the visit and met with Administrator (ADM) Julius Canonizado.

ADM stated resident R1 rarely uses his/her wheel chair. ADM stated R1 does not like to use it and will drop his/her weight on the floor, so that he/she isn't placed on the wheel chair. ADM stated R1 does not slide when using his vans seat belt. ADM stated R1 will also try to get out of the wheel chair as well as he/she does not like to be seated in the wheel chair.

LPA observed R1, who refused to be placed on the wheel chair. ADM attempted to place R1 on the wheel chair and R1 was not cooperating and did not want to sit on the wheel chair. ADM showed LPA the transportation van the facility uses for R1 and the car's seat belt which is used to transport R1.

ADM stated he will send a letter to rescind the exception request. ADM stated if there is a change of condition, R1 will notify LPA.

No deficiencies cited during todays visit. This report was reviewed with ADM Julius Canonizado and a copy was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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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