435202663-6-28-2024-26-AS-RMAO-D72VFS-20240710162425

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202663
Report Date: 06/28/2024
Date Signed: 06/28/2024 05:45:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
05/04/2022 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20220504093202

FACILITY NAME:	EVERGREEN HOME LIVING		FACILITY NUMBER:	435202663
ADMINISTRATOR:	ARANZASO, RHONALD		FACILITY TYPE:	740
ADDRESS:	3291 SYLVAN DR		TELEPHONE:	(408) 459-7888
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY:	6	CENSUS: 0	DATE:	06/28/2024
		UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Licensee/ Administrator, Thu Nguyen		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Insufficient staffing to meet the residents needs
Residents' P & I cash not readily available for residents use

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced complaint investigation to deliver the findings of a complaint investigation conducted by the Department. This is a follow up visit from the initial visit conducted on 5/10/2022. LPA met with Licensee/ Administrator, Thu Nguyen and stated the purpose of this visit.

On 5/4/2022, the Department received a complaint with the above allegations. On 5/10/2022, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024

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-20220504093202

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME LIVING	FACILITY NUMBER: 435202663
	VISIT DATE: 06/28/2024

NARRATIVE

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Page 2 of 3.
Insufficient staffing to meet the residents needs
It was alleged there were not enough staff in the facility.

Based on record review, 5 resident records which included San Andreas Regional Center Individual Program Plan (IPP), Physician's Report, and Appraisal Needs & Service Plan. Upon reviewing the documents, 4 out of the 5 residents need supervision and 1 out of the 5 residents needs 1:1 supervision. At the time of the alleged event, there were 5 residents at the facility. Based on review of LIC 500 Personnel Report and Employee Timecards for the dates April 24, 2022- May 6th, 2022, and 41 out of 42 shifts were reviewed, it was documented that 1 or 2 staff members for 5 residents were on shift at the facility.

On 5/10/2022, 2 staff (S1-S2) were interviewed. S1 stated the facility ratio should be 1 staff to 3 residents. S1 stated he/she is assigned to care for R3 for 1:1 supervision, but also supervises the other residents in the facility. Based on observation, LPA observed 2 staff members at the facility. S1 is assigned to be 1:1 care staff and S2 supervises 4 out of 5 residents at the facility.
On 5/10/2022, 1 out of 5 (R1) was interviewed. 4 Out of 5 residents declined to be interviewed. R1 stated the facility is good and has no issues.

Residents' P & I cash not readily available for residents use
It was alleged the resident's cash is not readily available for residents to use at the facility.

Based on observation, Licensee provided residents P&I cash during visit on 5/10/2022 and it was readily available for resident’s care. Licensee had the case box with her and brought the cash box to the facility within 2 hours of request. LPA reviewed cash box with Licensee, 5 out of 5 resident records of client’s/resident’s safeguarded cash resources (LIC 405) was reviewed and all money was account for during the visit.

Based on interview, S3 stated the licensee requires staff to give residents their money from their own pocket and the licensee will reimburse them afterwards, several days later. Licensee keeps the P&I cash in cash box not in a bank or another credited account.
On 5/10/2022, 1 out of 5 (R1) was interviewed. 4 Out of 5 residents declined to be interviewed. R1 stated the facility is good and has no issues.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220504093202

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME LIVING	FACILITY NUMBER: 435202663
	VISIT DATE: 06/28/2024

NARRATIVE

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Page 3 of 3.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3