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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202269
Report Date: 01/28/2026
Date Signed: 01/28/2026 06:23:02 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/28/2026 06:23 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 #1FACILITY NUMBER:
435202269
ADMINISTRATOR/
DIRECTOR:		EVELYN CANONIZADOFACILITY TYPE:
735
ADDRESS:3127 HAGA DR.TELEPHONE:
(408) 440-2887
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 4DATE:
01/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:15 PM
MET WITH:Romeo Ignacio, Wilfred Galat, Tessie FernandezTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds of this four bedroom home. There are 3 shared client bedrooms and a staff room, two common bathrooms, small living room and eat in kitchen. The yard is spacious, level, and fenced. Washer and dryer are located in two car garage There are no accessible bodies of water nor fire safety hazards observed. carbon monoxide detector is operable. Food supply and first-aid kit are inspected, and hygiene items for general use are maintained. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as required staff records. Evelyn Canonizado is a certified ARF administrator (x 12/26) that oversees facility operations. Client files are reviewed, and Centrally Stored Medications Records are maintained. Two clients are over age 60, and staff are advised that annual MD reports and appraisals must be maintained.

Personnel Report (LIC500) is requested to be updated and sent to CCLD by 2/11/26.





Deficiencies of the California Code of Regulations, Title 22, are cited on following pages. See also Technical Advisory Notes issued--2 pages.
NAME OF LICENSING PROGRAM MANAGER: Cowan April
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 01/28/2026 06:23 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/28/2026 at 05:38 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 #1
FACILITY NUMBER: 435202269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2026
Section Cited
CCR
80088(e)(1)

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FIXTURES, FURNITURE, EQUIPT...
Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F & not more than 120 degrees F. This requirement is not met,
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Hot water temperature to be lowered and maintained within range of 105 to 120 degrees. Proof/plan of correction to be sent to CCLD BY DUE DATE
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as hot water temperature tested at 132 degrees F in client bathroom. Licensee failed to ensure that hot water temperatures is maintained within range of 105 to 120 degrees, which poses an immediate health and safety risk to clients in care.
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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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2026 06:23 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/28/2026 at 05:59 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 #1
FACILITY NUMBER: 435202269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2026
Section Cited
CCR
85068.4(g)

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ACCEPTANCE & RETENTION LIMITS
If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60...or older exceeding 50 % of the census... the licensee must request an exception in order to accept or retain the individual.
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Age exception shall be submitted for client #3 or #4, with supporting documentation, including MD report, appraisal, consent letter from placement or responsible party .
Plan of correction to be sent to CCLD BY DUE DATE
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The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. Two clients are over 60 years old, and an age exception has not been requested/approved.
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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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
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