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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202326
Report Date: 04/26/2023
Date Signed: 04/26/2023 03:46:24 PM

Document Has Been Signed on 04/26/2023 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Evelyn CanonizadoTIME COMPLETED:
03:50 PM
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Licensing Program Analysts (LPAs) Simi Rai and Manuel Monter conducted an unannounced annual inspection visit and met with Administrator Evelyn Canonizado.

During visit, LPAs toured the inside and outside of the facility. All fire exit routes are free and clear of obstruction. LPAs toured the facility kitchen and observed at least 2 days of perishable food supply of at least 7 days of nonperishable food supply. Sharps and medications were locked in secured areas. There was a first aid kit in the facility. LPAs observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

The facility bathroom had available soap, paper towels, and trash cans with lids. The showers had grab bars, non-skid mats, and shower chairs. The water temperature in the bathroom sinks ranged from 116.1F - 116.6F. Fire extinguisher were observed and were inspected on March 2022. Administrator stated the next inspection for the fire extinguishers will be done May 2023.

LPAs observed the Bathroom #2 attached to Resident Room #1 and Room #2. The light switch was covered in tape and the lights were off. Staff S1 stated the light needs to be fixed and the light switch was covered to protect the residents while the facility waits for electrician to fix the lights. LPAs observed staff and residents using Bathroom #2. Administrator will replace the light inside Bathroom #2 and in the meantime will add night light in the bathroom. Administrator will submit a written plan to ensure the safety of the residents.

Page 1 out of 2. See LIC 809-C.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 04/26/2023 03:46 PM - It Cannot Be Edited


Created By: Simranjit Rai On 04/26/2023 at 02:11 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 #3
FACILITY NUMBER: 435202326

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2023
Section Cited

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80088 Furniture, Fixtures, Equipment, and Supplies - (d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by:
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Based on observation and interview, the licensee did not comply with the section cited above in Bathroom #2 attached to Resident Room #1 and #2 does not have a working light which poses an potential health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 #3
FACILITY NUMBER: 435202326
VISIT DATE: 04/26/2023
NARRATIVE
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Facility smoke and carbon monoxide detectors were tested and found to be in functioning condition. Three out of three resident bedrooms had available bedding, drawers, and functioning lights. LPAs reviewed facility records for seven staff and three residents. LPAs reviewed resident medications and central stored medication records. LPAs reviewed record of resident's safeguarded of cash resources. LPAs interviewed three staff and attempted to interview residents.

Technical Violation and Technical Assistance were issued. See LIC9102 pages for more information.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC 809-D.

This report was reviewed with Administrator Evelyn Canonizado. A copy of the report was provided. Appeal Rights were provided.

Page 2 out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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