435202601-6-25-2021-26-AS-KHOS-C4PNWQ-20210707104955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202601
Report Date: 06/18/2021
Date Signed: 06/25/2021 09:16:12 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/15/2021 and conducted by Evaluator Anna Bui

COMPLAINT CONTROL NUMBER: 26-AS-20210415133350

FACILITY NAME:	EVERGREEN RESIDENTIAL CARE HOME INC		FACILITY NUMBER:	435202601
ADMINISTRATOR:	DEVANO, DANTE		FACILITY TYPE:	740
ADDRESS:	5707 FLOWERING MEADOW COURT		TELEPHONE:	(408) 300-1054
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	6	CENSUS: 5	DATE:	06/18/2021
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Belinda Devano		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Lack of supervision resulting in resident eloping from facility.

INVESTIGATION FINDINGS:

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On 06/18/2021 at 11:17 am, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced complaint investigation visit to deliver the finding to the above allegation. LPA met with Administrator Belinda Devano.

On 04/23/2021, an initial 10-day complaint investigation was conducted, and the Administrator was interviewed. Administrator stated there is always a staff working at the facility. Administrator stated the facility has door alarms to signal staff when the door has been opened, and it was working that day. Administrator stated the residents are not able to leave the facility unsupervised. Administrator stated R1 left the facility through the front door without staff’s knowledge. Administrator stated staff did not see R1 leave and did not hear the door alarm sound.

Continued, see LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210415133350

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EVERGREEN RESIDENTIAL CARE HOME INC	FACILITY NUMBER: 435202601
	VISIT DATE: 06/18/2021

NARRATIVE

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On 04/23/2021, 3 residents were interviewed. 3 out of 3 residents stated they have never been left alone at the facility. 1 out of 3 residents stated they left the facility without staff when they weren’t supposed to. 2 residents were not able to be interviewed because they were sleeping or refused to be interviewed.

On 04/23/2021, 2 staff were interviewed. 2 out of 2 staff stated they check on the residents often, and there is always a staff working at the facility. 2 out of 2 staff stated there are door alarms at the facility, and they were working properly before the incident. 1 out of 2 staff stated S1 did not hear the alarm go off and did not hear or see R1 leave the facility. S1 stated when completing night rounds, S1 noticed R1 was not in R1’s bed and was not able to locate R1.

On 04/23/2021, a tour of the facility was conducted. Door alarms were observed and working properly. Administrator opened the door and the alarm made a sound immediately.

Records review were also conducted. On 04/16/2021, the Department received an incident report stating on 04/15/2021, staff was not able to locate R1 in R1’s bed and was not able to find R1 in the facility. San Jose Police Department was notified, and a missing person’s report was made. R1’s Physician Report was also reviewed and showed that R1 is not able to leave the facility unassisted.

San Jose Police Department Incident Report was also reviewed. The report stated that on 04/15/2021, the facility reported R1 missing. A witness found R1 and reported it to the San Jose Police Department, where an officer responded and verified it was R1.

The Department has conducted an investigation of the above allegation. Based on interviews, observations, and records review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

A deficiency is being cited. See LIC 9099-D.

Exit interview was conducted with Administrator Belinda Devano. This report, LIC 9099-D and Appeal rights were discussed and a copy was left with Administrator Belinda Devano.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210415133350

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EVERGREEN RESIDENTIAL CARE HOME INC	FACILITY NUMBER: 435202601
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/19/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall... include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee increased night shift monitoring of residents to at least twice a night and documenting daily checks. Door alarms are checked every 4 hours and documented in a log book. LPA observed documentation of daily resident checks and alarm door checks. LPA observed POC completed on site.
	8 9 10 11 12 13 14	Based on interviews, observation, and records review, Staff (S1) did not ensure resident (R1) who can’t leave facility unassisted was supervised while leaving the facility. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

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