435202269-2-2-2023-26-AS-KHOS-CP5KZB-20230217072027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202269
Report Date: 02/02/2023
Date Signed: 02/02/2023 11:03:59 AM

Unsubstantiated

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
08/19/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20220819110732

FACILITY NAME:	EVERGREEN GUEST HOME #1		FACILITY NUMBER:	435202269
ADMINISTRATOR:	EVELYN CANONIZADO		FACILITY TYPE:	735
ADDRESS:	3127 HAGA DR.		TELEPHONE:	(408) 440-2887
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95111
CAPACITY:	6	CENSUS:	DATE:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:			TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident was physically abused while in care
Resident was sexually abused while in care

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) David Marrufo and Manuel Monter conducted an unannounced complaint investigation visit and met with Marina Gumarad.

On 08/19/2022, the Department received a complaint with the above allegations. On 08/19/2022, the Department conducted an initial complaint investigation visit and conducted further investigation at later dates.

Staff and residents who were interviewed corroborated that resident R1 punched resident R2 in the arm after a dispute in the kitchen. However, residents, including R1 and R2, and staff state that this was the first time they saw R1 physically hit R2. Staff are only able to deescalate and redirect, in which they acted accordingly and attempted to separate the two clients to deescalate. Staff felt the incident was diffused, but R1 unexpectedly hit R2 without warning.

See LIC812-C for more information. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 26-AS-20220819110732

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 #1	FACILITY NUMBER: 435202269
	VISIT DATE: 02/02/2023

NARRATIVE

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R2 denied R1 ever touched R2’s private parts. R1 also denied ever touching R2’s private parts. R2 mentioned R1 once attempted to touch R2’s pelvis area, but when R2 told R1 “not to do that,” R1 complied and stopped.

Staff denied seeing inappropriate behavior between R1 and R2, but Licensee stated R1 and R2 have been caught touching each other while in the living room with other clients. Licensee stated that staff would tell them to stop, and prompt that their actions should be in private, and not in public in front of clients and other staff. The licensee told San Jose Police Department (SJPD) that R2 disclosed to licensee that sometimes R2 liked being touched by R1 and sometimes R2 did not. Residents reported that they suspected something going on between R1 and R2 because they would sneak into each other’s room.

Based on information from interviews conducted with staff and residents, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Marina Gumarad as well as over telephone with Administrator Evelyn Canonizado and a copy of the report was provided.

Page 2 of 2.

END REPORT

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2