Senior Care Records.

Facility Evaluation Report

Evergreen Guest Home #4, San Jose07/30/2024Licence 435202168

Capacity6
Census4
Date signed07/30/2024 02:39:23 PM
The inspector’s account

Licensing Program Analyst Manuel Monter conducted an unannounced case management visit-Other pertaining to resident R1's postural support exception. LPA explained the purpose of the visit and met with Administrator (ADM) Julius Canonizado.

ADM stated resident R1 rarely uses his/her wheel chair. ADM stated R1 does not like to use it and will drop his/her weight on the floor, so that he/she isn't placed on the wheel chair. ADM stated R1 does not slide when using his vans seat belt. ADM stated R1 will also try to get out of the wheel chair as well as he/she does not like to be seated in the wheel chair.

LPA observed R1, who refused to be placed on the wheel chair. ADM attempted to place R1 on the wheel chair and R1 was not cooperating and did not want to sit on the wheel chair. ADM showed LPA the transportation van the facility uses for R1 and the car's seat belt which is used to transport R1.

ADM stated he will send a letter to rescind the exception request. ADM stated if there is a change of condition, R1 will notify LPA.

No deficiencies cited during todays visit. This report was reviewed with ADM Julius Canonizado and a copy was provided.

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