435202663-4-18-2022-26-AS-KHOS-CECJV7-20220512072236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202663
Report Date: 04/18/2022
Date Signed: 04/18/2022 04:58:13 PM

Unsubstantiated

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
05/06/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20210506153222

FACILITY NAME:	EVERGREEN HOME LIVING		FACILITY NUMBER:	435202663
ADMINISTRATOR:	KUMAR, SASHI		FACILITY TYPE:	740
ADDRESS:	3291 SYLVAN DR		TELEPHONE:	(408) 459-7888
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY:	6	CENSUS: 5	DATE:	04/18/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Thu Nguyen, Licensee		TIME COMPLETED:	04:39 PM

ALLEGATION(S):

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The facility does not have canned foods.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint visit to deliver investigation finding. LPA met with Licensee (LNS) Thu Nguyen.

On 05/06/2021, the Department received a complaint of the above allegation. On 05/12/2021, an unannounced complaint inspection visit was conducted. During the investigation, LPA interviewed two staff and four residents and toured the facility. Residents roster, 4 weeks of facility food menu, staff duty schedule, and monthly grocery shopping list proposed by ADM were obtained.

Continued, see LIC 9099-C, pages 1 of 3

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20210506153222

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 HOME LIVING	FACILITY NUMBER: 435202663
	VISIT DATE: 04/18/2022

NARRATIVE

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The facility does not have canned foods:

On 05/12/2021, LPA visited facility and inspected the foods in the refrigerator and foods in the pantry. LPA observed the foods in the refrigerator around half of capacity of the refrigerator, and the foods in the pantry around 1/3 of the capacity of the pantry with 15 cans of food.

On 05/12/2021, two staff were interviewed. 2 out of 2 stated the supply of perishable food is less than 2 days and the nonperishable food supplies is less than 4 days. However, 1 out of 2 staff interviewed stated she never had the situation where there was no food to cook. LPA interviewed four residents (R1 - R4). Two residents stated that they always have enough foods for 3 meals and two snacks. The other two residents stated they do not have any complaint.

On 06/23/2021, LPA visited the facility and inspected the foods in the refrigerator and the foods in the pantry in the facility. LPA observed the foods in refrigerator and foods in pantry were more than 2/3 of the capacity. The 2 day perishable food supplies and 7 day nonperishable food supplies were observed sufficient. Two additional staff were interviewed and stated the condition of food supply in stock was getting better than one month ago.

On 07/19/2021, LPA inspected the foods in the refrigerator and foods in the pantry with administrator (ADM). LPA observed the foods in refrigerator were full, and the foods in the pantry were almost full. Licensee (LNS) stated LNS goes grocery shopping at least two times per week. The 2 day perishable food supplies and 7 day nonperishable food supplies were observed sufficient.

Continued, see LIC 9099-C, pages 2 of 3

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 26-AS-20210506153222

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 HOME LIVING	FACILITY NUMBER: 435202663
	VISIT DATE: 04/18/2022

NARRATIVE

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On 5/12/2021, 6/23/2021, and 7/19/2021 during the investigation visit, facility was observed to have sufficient canned food. There are no picture that staff or residents can provide to show that the facility did not have canned food. No residents complained the food supplies were not enough.

The department has investigated the above allegation. Based on the investigation, observations, records reviewed, and interviews conducted, the Department found that the above allegations is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with Licensee. This report was provided for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC9099 (FAS) - (06/04)

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