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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206774
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:27:10 PM


Document Has Been Signed on 02/15/2024 02:27 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:EVERGREEN GARDENSFACILITY NUMBER:
107206774
ADMINISTRATOR:STEPHANIE UYEMURAFACILITY TYPE:
740
ADDRESS:10775 E. TULARE AVE.TELEPHONE:
(559) 454-1915
CITY:SANGERSTATE: CAZIP CODE:
93657
CAPACITY:6CENSUS: 2DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Stephanie UyemuraTIME COMPLETED:
02:45 PM
NARRATIVE
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On 2/15/2024 Licensing Program Analyst (LPA) K.Kaur arrived at facility unannounced to complete an Annuel inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Direct Care Staff, Patricia Gonzalez. Administrator Stephanie Uyemura was contacted and arrived a short time later.

Facility has 6 bedrooms with one resident residing in Bedroom 6 and one resident in Bedroom 4. LPA toured the facility with the staff. Tour started at the facility kitchen. Knives were locked in the kitchen cabinet. LPA observed 7-day supply of non-perishable foods and 2-day supply of perishable foods. Cleaning supplies observed locked in the cabinet next to the pantry. Laundry area toured and observed with locks on all cabinets. The dining room is equipped with a table and chairs, the living room is equipped with adequate sofas and recliners for seating. Medications, first aid kit observed locked in the hallway closet. Parlor observed with games and activities. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available in hallway closet. Hot water temperature measured at 98.9 degrees F. LPA observed grab bars installed by toilet and non-skid mats in place. Smoke alarm detectors and Carbon monoxide detectors installed and operational. Adequate outside space for rest and recreational. Sufficient seating observed under covered patio. The fire extinguisher in kitchen was serviced 3/21/2023. Backyard gate is self-closing and self-latching. At 11:58 AM LPA observed an unlocked shed in the backyard that has tools and chemicals.

Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report
and ID Documentation. At 12:45 PM LPA observed during file review; one resident and administrator did not have records of TB test on file. Staff files were reviewed for good health. It was verified that current staff on duty is CPR certified. Last Fire Drill conducted on 1/08/2024.

Continued to 809C...
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: EVERGREEN GARDENS
FACILITY NUMBER: 107206774
VISIT DATE: 02/15/2024
NARRATIVE
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Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 2/22/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with staff. Report signed on-site; a copy of this report, 809D with appeal rights was provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/15/2024 02:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: EVERGREEN GARDENS
FACILITY NUMBER: 107206774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1; shed observed unlocked with tools and chemicals which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee to ensure the tool shed is kept locked. Administrator locked the shed immediately.
Type A
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 residents file revieled not TB test on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licnesee to obtain and keep all residents TB results on file and ensure before admitting residents to the facility tests are completed and on file
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: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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