430707505-10-16-2024-26-AS-RMAO-DA8TZB-20241020151004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430707505
Report Date: 09/28/2024
Date Signed: 10/16/2024 03:13:27 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
03/10/2023 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20230310144550

FACILITY NAME:	EVERGREEN GUEST HOME #2		FACILITY NUMBER:	430707505
ADMINISTRATOR:	CANONIZADO, E. & F.		FACILITY TYPE:	735
ADDRESS:	1628 MCLAUGHLIN AVENUE		TELEPHONE:	(408) 286-5985
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95122
CAPACITY:	6	CENSUS: 6	DATE:	09/28/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Lead Staff Robert Foronda		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff unable to supervise and redirect a resident who had a violent behavior resulting in resident's elopement from the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Lead Staff Robert Foronda
On March 10, 2023, the Department received a complaint alleging Staff unable to supervise and redirect a resident who had a violent behavior resulting in resident's elopement from the facility. It has been alleged this incident took place on February 23, 2023.
Based on Records reviewed, Staff S1 is R1's 1 on 1 care giver. Staff S2, and S3 are home health staff that were scheduled for R1 on February 23, 2023.
On September 14, and 22, 2024, Licensing Program Analyst Manuel Monter interviewed staff S1, S4, S5. Staff S1 stated R1 was having a behavior that day and had struck one of the staff. S1 stated after R1 had struck a staff member, R1 ran towards the front door. S1 stated he/she followed R1 outside. S1 stated when he/she was chasing after R1, S1 stated he/she was also trying to call out and redirect R1 back to the home. S1 stated he/she followed R1 until R1 had calmed down and redirected R1 back home. S1 stated he/she followed R1 and R1 was not left unsupervised. Page 1 Out of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024

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-20230310144550

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 GUEST HOME #2	FACILITY NUMBER: 430707505
	VISIT DATE: 09/28/2024

NARRATIVE

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Staff S4 stated he/she was staying in the staff room sleeping (live in staff). S4 stated he/she heard some noise and exited the staff room to investigate. S4 stated he saw R1 throw small speaker and he/she tried to intervene but R1 threw it. S4 stated R1 went outside and (S1) followed him/her. S4 stated S1, brought R1 back. Staff S5 stated she was not in the home when the alleged incident took place and has no knowledge of the incident.
On September 14, 2024, LPA Monter interviewed residents R2-R6. 3 Out of 5 residents (R3, R5, R6) stated they didn’t know or see R1 eloping from the facility on February 23, 2023. R1. 2 Out of 5 residents (R2, R4) interviewed were unable to provide answers to LPA's questions. Residents interviewed had were being distracted and engaging in other actions such as playing with toy/tablet.
On September 28, 2024, LPA interviewed ADM. ADM stated, the 1 on 1 staff followed R1. ADM stated staff S1 was running after R1 who was having a behavior. ADM stated S1 brought R1 back to the home.

On October 16, 2024, LPA Monter interviewed staff S2 and S3. S2 stated R1 was having a behavior when he/she head butt S3. S2 stated he/she assisted S3 up and observed R1 running toward the front door, while S1 followed. Staff S3 stated he/she was head butt by R1 and does not know what had happened. S3 stated a staff member was helping him/her and was brought to the bathroom because he/she was dizzy and his/her nose was bleeding. S2 and S3 stated staff S1 went running after R1 as he/she ran towards the front door. S2 and S3 stated Staff S1 brought R1 back to the facility.
Based on a review of R1’s Needs & Services Plan, dated March 25, 2022, the form states if R1 problem (wants/needs) is not resolved, it can escalate to maladaptive behavior like throwing things, going after staff and AWOL.

Based on a review of a San Andreas Regional Center incident Report for the date February 23, 2023, when R1 arrived from the school van he/she was being escorted inside the facility. R1 then started hitting the staff at the front door. Staff assisted R1 to his/her room and R1 continued to hit staff. The staff ran outside the group home and R1 followed. Staff were able to bring R1 into the home.

The Department was unable to interview Resident R1, who no longer lives at the facility.
Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are 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.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024

LIC9099 (FAS) - (06/04)

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