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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202269
Report Date: 08/24/2022
Date Signed: 08/24/2022 04:11:14 PM

Document Has Been Signed on 08/24/2022 04:11 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:EVELYN CANONIZADOFACILITY TYPE:
735
ADDRESS:3127 HAGA DR.TELEPHONE:
(408) 440-2887
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 6CENSUS: 6DATE:
08/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Evelyn CanonizadoTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (ADM) Evelyn Canonizado. The purpose of the visit was to investigate an incident that was reported by the facility via Unusual Incident/Injury Report stating that staff S1 was found to have tied the door knob of the hallway door to a couch at night.

During visit, LPA Marrufo interviewed Administrator Canonizado regarding the incident. ADM Canonizado stated that the incident occurred on 08/15/2022 when police arrived at the facility in response to another incident. The police arrived at around 11:30 PM and entered the side gate of the facility and came around to the rear door of the facility. The police knocked on the rear door and S1 answered the door. Upon entering the facility, the police observed the hallway door to be tied to a foot of the couch by the hallway. The police called ADM Canonizado and when ADM Canonizado arrived, the police showed her a photograph of the door as the police found it upon their arrival. ADM Canonizado states that the photograph showed the hallway door knob tied with two or three shoe strings tied together to one of the feet of the couch by the hallway. ADM stated that the police officers did not provide her with the photograph.

ADM Canonizado states that S1 was a live in staff and was relieved of duty immediately when ADM arrived. ADM stated that S1 has not worked at the facility since the incident. During visit, LPA Marrufo reviewed the staffing schedule and confirmed that S1 was no longer scheduled to work at the facility.

During visit, LPA Marrufo interviewed residents R1-R5 and attempted an interview with R6.

LPA Marrufo interviewed staff S1-S2. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D for more information. This report was reviewed with Administrator Evelyn Canonizado and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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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Document Has Been Signed on 08/24/2022 04:11 PM - It Cannot Be Edited


Created By: David Marrufo On 08/24/2022 at 03:57 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: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2022
Section Cited
CCR
80072(a)(7)

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80072(a)(7) Personal Rights: Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: Not to be locked in any room, building, or facility premises by day or night.
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Licensee agrees to submit a plan to CCL by POC date to train facility staff in resident's Personal Rights, including the right to not be locked in any part of the facility. Once training is completed, the licensee agrees to submit training rosters including training topics, name and qualifications of trainer(s), names of
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This requirement was not met as evidenced by: Licensee did not ensure that the hallway door was not locked at night, keeping residents from entering the living room and kitchen areas, which posed an immediate safety risk to residents in care.
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staff trained, and training dates to CCL.

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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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022


LIC809 (FAS) - (06/04)
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