Senior Care Records.

Facility Evaluation Report

Evergreen Guest Home #4, San Jose04/12/2024Licence 435202168

Capacity6
Census5
Date signed04/12/2024 03:30:10 PM
The inspector’s account

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator (ADM) Julius Canonizado.

While investigating the complaint 26-AS-20220711133100 , LPA reviewed R1’s Individual Program Plan (IPP), dated February 22, 2022. R1's IPP states, R1 is non-ambulatory and uses a manual wheelchair independently. The IPP states; R1 is observed to slide down on his seat during transport. Posey vest/gait belt need to ensure R1's safety/well-being. The form also states R1 is required to have a gait belt/poesy vest.

On July 15, 2022, the Department interviewed ADM. ADM stated R1 needs the chest harness because he/she doesn’t have control over his body.

On April 12, 2024, LPA interviewed ADM. ADM stated R1 is currently using his/her wheel chair. ADM stated R1's wheel chair has a chest strap and a lap belt.

Based on a facility file review, the facility does not have an exception for the postural support device.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Julius Canonizado. A copy of the report and appeal rights were provided.

Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction