435202269-7-21-2023-26-AS-KHOS-CW8J6Q-20231002064642

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202269
Report Date: 07/21/2023
Date Signed: 07/21/2023 09:43:01 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
07/13/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20220713143206

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: 6	DATE:	07/21/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Marina Gumarad		TIME COMPLETED:	09:55 AM

ALLEGATION(S):

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Facility's food services are inadequate
Facility is financially abusing resident(s) in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo and Deputy Director Kevin Gaines conducted an unannounced complaint investigation visit and met with staff Marina Gumarad.

On 07/13/2022, the Department received a complaint with the above allegations. On 07/20/2022, LPA Marrufo conducted an initial complaint investigation visit.

On 07/14/2023, the Department interviewed Administrator (ADM) on the phone. ADM stated that he/she purchased groceries every week. ADM stated that San Andreas Regional Center (SARC) conduct visits at the facility to inspect food supplies. ADM stated so far, he/she has not received a corrective action on food supplies, and food being served to residents from SARC.

See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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 3

Control Number 26-AS-20220713143206

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: 07/21/2023

NARRATIVE

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ADM stated that R1 thought that the facility is a restaurant wherein he/she can order food differs from what is being served per the facility menu. ADM stated that R1's request is being adhered to but at times it creates an issue from other residents because he/she was being served a different food. ADM stated that residents are being served 3 meals and snacks.

ADM stated that they have plenty of food supplies, and R1 enjoys eating cereal yet he/she refrain from eating them due to high sugar content. ADM stated that they serve hotdogs, ham sandwiches and fruits to R1. ADM states that staff follow their menu but when residents do not want anything from the food menu, residents are given what they prefer to have. ADM stated that R1 does not complaint about the food served at the facility rather R1 does not normally eat dinner. ADM stated that R1 does not eat meat. ADM stated that R1 enjoys burritos but dislikes oatmeal. ADM stated that R1 does not eat oatmeal.

On 07/14/2023, the Department interviewed Staff (S1). S1 stated that R1 stated that R1 never brought up about food served by staff. S1 stated he/she knew that R1 is particular with certain foods such as oatmeal and R1 does not eat dinner. S1 stated that they served food based on their menu and they have plenty of food supplies. S1 stated that when R1 refuses to eat dinner, R1 does not tell them the reason why. S1 stated that they provide 3 meals and snacks.

ADM stated that he/she does not use R1's Personal and Incidental money (P & I) for facility groceries. ADM denied allegation of financially abusing R1. ADM stated that R1's P & I monies are spent by R1 by purchasing his/her needs such as shopping online and clothing. ADM stated that R1 is verbal and oriented who knows when to ask for his/her P & I money. ADM stated that R1 received his/her monthly P & I of $188.00 and currently R1 has $400.00. ADM stated that R1 signs their P & I ledger when he/she withdraws money, and receipts are kept.

Page 2 of 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 26-AS-20220713143206

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: 07/21/2023

NARRATIVE

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ADM stated that the facility has plenty of food and there are 1 freezer and two refrigerators. ADM stated, "Why should I spend residents' money? I don't want to get in trouble." ADM stated that SARC (San Andreas Regional Center) does visit the facility to conduct their inspections including review of residents' P & I. ADM stated that if there is an issue with P & I, the facility licensee would have received a corrective action from SARC.

Based on information from interviews conducted with staff, and records reviewed, 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 cited under California Code of Regulations Title 22

This report was reviewed over the telephone with ADM Evelyn Canonizado and a copy of this report was provided.

Page 3 of 3. END REPORT.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3