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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202326
Report Date: 11/18/2024
Date Signed: 11/18/2024 01:47:33 PM

Document Has Been Signed on 11/18/2024 01:47 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/
DIRECTOR:
EVELYN CANONIZADOFACILITY TYPE:
735
ADDRESS:1128 BENDMILL WAYTELEPHONE:
(408) 362-0994
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 6CENSUS: 6DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Staff S1, Nida ReguindinTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff S1,Nida Reguindin. During the visit, LPA observed 2 residents and 2 staff. LPA explained the purpose of the visit.

Staff S1 contacted ADM and informed her that LPA had arrived to conduct an annual inspection. ADM informed LPA that the staff files and residents P&I records were with her. ADM stated she won't would be able to arrive to the facility, so LPA can review residents P&I records and staff files.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. LPA also toured the facility garage, which is being used as a storage place/ Laundry area. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring resident bedroom #1, LPA observed the wall directly next to a residents bed, closest to the door, leading outside. LPA observed the wall directly next to the bed had its paint peeled off, revealing the drywall. S1 stated resident R1 has a behavior of peeling the paint from the wall. (Photographs were taken.) S1 stated R1 has been peeling the paint since he/she moved into the home.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 74 degrees F, and hot water temperature ranged from 107-109 degrees F in both resident bathrooms.

Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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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: 11/18/2024
NARRATIVE
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Fire extinguisher was serviced in September 26, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit. LPA requested to review the facility file drill log. S1 stated the log is in the locked cabinet.

LPA reviewed facility records for 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 1 residents.

LPA called ADM at 1:42pm. ADM stated she is in a meeting and would not be able to come to the facility. ADM stated staff S1 could sign on her behalf.

Deficiencies are being cited during today's visit. This report was reviewed with Staff S1, Nida Reguindin and a copy of the signed report was provided.

Page 2 Out of 2. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2024 01:47 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/18/2024 at 01:25 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: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed, in resident bedroom #1 the wall directly next to a residents bed, closest to the door, leading outside. LPA observed the wall directly next to the bed had its paint peeled off, revealing the drywall. S1 stated resident R1 has a behavior of peeling the paint from the wall. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of the residents. ADM stated she will send photo documentation showing the drywall is no longer exposed, by POC date November 25, 2024.
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to review residents P&I records. ADM stated she had the records with her and would not be able to arrive to the facility on time, for LPA to review. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send the written letter by POC date, November 25, 2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2024 01:47 PM - It Cannot Be Edited


Created By: Manuel Monter On 11/18/2024 at 01:25 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: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to review the facility fire/earthquake/disaster drill log. LPA was not provided drill log to review during visit. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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ADM stated she will conduct a drill and send LPA documentation showing a drill has taken place. ADM stated she will send the plan of correction by POC date, November 25, 2024.
Type B
Section Cited
CCR
80066(c)
80066 Personnel Records (c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA requested to review staff records. ADM stated she had the records with her and would not be able to arrive to the facility on time, for LPA to review. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send the written letter by POC date, November 25, 2024.
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
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