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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206775
Report Date: 03/18/2024
Date Signed: 03/18/2024 03:30:22 PM


Document Has Been Signed on 03/18/2024 03:30 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 MEADOWSFACILITY NUMBER:
107206775
ADMINISTRATOR:STEPHANIE UYEMURAFACILITY TYPE:
740
ADDRESS:10691 TULARE AVENUETELEPHONE:
(559) 453-8773
CITY:SANGERSTATE: CAZIP CODE:
93657
CAPACITY:6CENSUS: 6DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Licnesee/ Administrator Stephanie UyemuraTIME COMPLETED:
03:40 PM
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On 3/18/2024 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, Esmeralda Gomez. Licnesee/ Administrator Stephanie Uyemura was contacted and arrived a short time later.

The facility has 6 residents, of which all were present during the inspection. LPA toured the facility with the staff. Tour started at Bedroom # 4. Knives were locked in the kitchen cabinet. LPA observed a 7-day supply of non-perishable foods and 2-day supply of perishable foods. Cleaning supplies observed locked in the cabinet next in the laundry cabinets. The 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. At 11:20 AM LPA observed Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) was letter size instead of 20 X 26. 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 beds, dresser, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available in the hallway closet. 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 a covered patio. The fire extinguisher in kitchen was serviced 3/22/2023. Backyard gate is self-closing and self-latching.

Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report and ID Documentation. During Medication review LPA observed Centrally Stored Medication and destruction record was incomplete. At 1:33 PM LPA observed R2’s PRN medication log had 3 entries; however, 7 pills were missing from pill pack. Staff files were reviewed for good health. Staff files had health screenings/ TB Clearance. It was verified that current staff on duty are CPR certified. Last Fire Drill conducted on 1/03/2024.

Continued to 809C...
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
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 5


Document Has Been Signed on 03/18/2024 03:30 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 MEADOWS
FACILITY NUMBER: 107206775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

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 PRN medication reviewed and did not have record of date and time the PRN medication was taken, the dosage taken, and the resident's response. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Licnesee to submit statement of intent by due date to complete an in-service training with staff regarding PRN medication protocol. Training records to be submitted to CCLD once completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 03/18/2024 03:30 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 MEADOWS
FACILITY NUMBER: 107206775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 Residential Care Facility for the Elderly (RCFE) Complaint Poster was not 20” x 26” which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Licnesee to post Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475). The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. Licnesee to submit pictures by due date to CCLD.

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: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


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 MEADOWS
FACILITY NUMBER: 107206775
VISIT DATE: 03/18/2024
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 3/25/2023: 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 Licnesee. Report signed on-site; a copy of this report, 809D with appeal rights was provided via email due to technical difficulties.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/18/2024 03:30 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 MEADOWS
FACILITY NUMBER: 107206775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)

87465(h)The following requirements shall apply to medications which are centrally stored (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

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 6 out of 6 residents Centrally Stored Medication and destruction record (CSMDR) was incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2024
Plan of Correction
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Licnesee to complete/update all residents Centrally Stored Medication and destruction record (CSDMR) with the current cycle medications and submit copies to CCLD by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5