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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202168
Report Date: 03/06/2025
Date Signed: 03/06/2025 01:55:57 PM

Document Has Been Signed on 03/06/2025 01:55 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:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Staff S1, Maribel DadacayTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff S1, Maribel Dadacay. During the visit, LPA observed 4 residents and 3 staff. LPA explained the purpose of the visit. Staff S1 contacted ADM via phone call. ADM stated he was unable to come to the facility due to a family members illness. ADM stated facility staff would be able to assist LPA with visit.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The 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 storage area, 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 112 degrees F in both resident bathrooms.

Fire extinguisher was serviced in September 26, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit. LPA requested to review facility drill log. The last drill conducted was on January 7, 2025. ADM stated he could not find records for drills conducted in 2024.

LPA reviewed facility records for 3 residents. LPA requested to review resident R2's preadmission appraisal. ADM confirmed R2 moved into the facility during the covid period. Facility staff was unable to provide a copy of R2's preadmission appraisal to review. LPA reviewed 3 staff records. LPA reviewed 3 P&I records.

Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/06/2025
NARRATIVE
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LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records.

While reviewing 3 residents medication records, LPA observed 2 cockroaches in the facility kitchen. LPA observed several ants, in the living room, next to the staff check in. (Photographs were taken.)

Deficiencies are being cited during today's visit. This report was reviewed with Staff S1, Maribel Dadacay and a copy of the signed report was provided.

Page 2 Out of 2. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/06/2025 01:55 PM - It Cannot Be Edited


Created By: Manuel Monter On 03/06/2025 at 01:37 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: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed 2 cockroaches in the facility kitchen. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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ADM stated he will send a written plan of action on how he will ensure the facility free of flies and other insects.
ADM stated he will send the written plan of action to LPA by POC date, 3/13/2025.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA requested to review facility drill log. The last drill conducted was on January 7, 2025. ADM stated he could not find records for drills conducted in 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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ADM stated he will send a written plan of action on how he will ensure the facility conducts a drill at least quarterly. ADM stated his plan will have Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. ADM stated he will send the written plan of action to LPA by POC date.
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: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 01:55 PM - It Cannot Be Edited


Created By: Manuel Monter On 03/06/2025 at 01:39 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: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.1(b)
85068.1 Admission Procedures (b) No client may be admitted prior to a determination of the facility's ability to meet the needs of the client, which must include an appraisal of his/her individual service needs as specified in Sections 80068.2 and 85068.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA requested to review resident R2's preadmission appraisal. ADM confirmed R2 moved into the facility during the covid period. Facility staff was unable to provide a copy of R2's preadmission appraisal to review. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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ADM stated he will write a letter of understanding regarding the regulation. ADM stated he will send LPA plan of action to LPA by POC date, 3/13/25
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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