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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202812
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:45:42 PM

Document Has Been Signed on 01/09/2025 03:45 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 HOMEFACILITY NUMBER:
435202812
ADMINISTRATOR/
DIRECTOR:		TRAN, ANTHONYFACILITY TYPE:
735
ADDRESS:5991 SOUTH SURF CT.TELEPHONE:
(408) 677-4520
CITY:SAN JOSESTATE: CAZIP CODE:
95138
CAPACITY: 6CENSUS: 6DATE:
01/09/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator Thuy TranTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management-incident regarding an incident which occurred where Resident (R1) eloped from the facility. LPA Monter met with Administrator Thuy Tran and stated the purpose of today's visit.

On December 30, 2024, the Department received an incident report (IR) stating the following, “ On December 27, 2024 around 2pm, staff was working with another resident regarding his/her P&I in the kitchen while R1 was in the living room watching television in the sofa. After the other resident left, he/she left the front door open. While staff was in the kitchen balancing P&I, R1 left the home without staff’s knowledge. This staff and R1 were the only individual’s home at this time. When staff noticed that R1 was not in the home, he/she ran down the block to search for R1 and informed Administrator and other staff nearby to help search for R1. Within 5 minutes of the search, R1 was found with SJPD, one block from the home. R1 was returned to the home without further incident. … Staff have also been instructed to provide constant supervision to avoid another unauthorized absence. “

On December 27, 2024, at about 2:11pm Local Law Enforcement (LLE) responded to a report of resident with developmental disabilities, trying to run into a busy street. LLE arrived at the scene at 2:15pm

On January 9, 2025, LPA Manuel Monter attempted to interviewed R1. Resident R1 did not answer LPA's questions. R1 was asking for a snack and walked away from LPA



Page 1 Out of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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
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 HOME
FACILITY NUMBER: 435202812
VISIT DATE: 01/09/2025
NARRATIVE
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On January 9, 2025, LPA Manuel Monter interviewed Staff S1. S1 stated the day of the elopement, he/she was in the home with 2 residents. S1 stated resident R2 was leaving and requesting to take some P&I money. S1 stated during that transaction, R1 had left the facility. S1 stated after he/she had finished giving the P&I, S1 stated he/she noticed R1 was no longer in the home. S1 stated this occurred a few minutes before 2:00pm. S1 stated he/she searched the home for R1, and when he/she could not find R1, he/she contacted the ADM. S1 stated he/she then went to search outside the home and as he/she was walking up the street, S1 stated he/she saw the police, neighbors and R1, on Tennant Ave, between Southlite Ct and S Breeze Ct. S1 stated, the police brought R1 back to the facility. S1 stated R1 did not have any injuries.

Based on a google maps search, the distance between the facility, and where staff S1 stated R1 was found is 0.1 miles away from the facility.

On January 9, 2025, LPA observed the front of the home no longer had the garage door. LPA observed the front of the home, where the garage door was located, now has a door and two windows. (Photographs were taken.) LPA asked ADM if she notified Community Care Licensing, prior to constructions. ADM stated no. ADM sent LPA email a copy of the building permits.

Based on a review of R1’s Physicians Report, dated September 15, 2024, R1 cannot leave the facility unassisted. A review of R1’s Appraisal/Needs & Services Plan, dated February 23, 2024, one of R1’s listed is, “attempts of eloping.”

Based on a review of R1’s Individual Program Plan (IPP), dated November 17, 2023, R1’s IPP states (Page 4), “R1 has a history of eloping from school or home.”

An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, wherein R1 eloped from the facility on December 27, 2024.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with ADM Thuy Tran. Appeal rights were provided. Page 2 Out of 2. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/09/2025 03:45 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/09/2025 at 02:28 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 HOME
FACILITY NUMBER: 435202812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2025
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by;
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ADM stated she will conduct staff training regarding residents with elopement behaviors. ADM stated she will send LPA documentation showing who attending, the training, how long the training was, and a summary of what was discussed.
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Based on interview and record review, on December 27, 2024, R1 left the facility unassisted and was found by law enforcement 0.1 mile away from the facility. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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ADM stated she will send documentation the training has taken place to LPA by POC date, January 10, 2025.
Type B
01/16/2025
Section Cited
CCR80086(a)

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80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
This requirement was not met as evidenced by;
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ADM stated she will send LPA a copy of permits for the changes in the facility garage. ADM stated she will send a written plan of action on how she will ensure the residents safety during the construction process.
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Based on interview and record review, the facility made alterations to the facility garage. ADM stated she did not notify Licensing prior to construction. This poses a potential health, safety or personal rights risk to residents in care.
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ADM stated she will send the plan of correction to LPA by POC date, January 16, 2025.
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: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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