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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202326
Report Date: 04/22/2022
Date Signed: 04/22/2022 03:46:08 PM

Document Has Been Signed on 04/22/2022 03:46 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
CCLD Regional Office,
, CA
FACILITY NAME:EVERGREEN GUEST HOME #3FACILITY NUMBER:
435202326
ADMINISTRATOR:EVELYN CANONIZADOFACILITY TYPE:
735
ADDRESS:1128 BENDMILL WAYTELEPHONE:
(408) 362-0994
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
04/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Evelyn CanonizadoTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to conduct a Case Management Visit regarding the Death Report for resident (C1). LPA met with Evelyn Canonizado Administrator and Nida Reguindin Caregiver.

LPA toured the facility inside and out. LPA interviewed the Administrator, 2 staff and reviewed C1 client records.

C1 passed away on 4/19/2022. The cause of death is to be confirmed. Additional information is need to complete the Case Management.

LPA reviewed this report with Evelyn Canonizado Administrator and a copy provided.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2022
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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