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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208848
Report Date: 02/23/2023
Date Signed: 02/23/2023 02:00:07 PM


Document Has Been Signed on 02/23/2023 02:00 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:EVERSPRING RETIREMENT HOMEFACILITY NUMBER:
107208848
ADMINISTRATOR:AZADEH AKBARNEJADFACILITY TYPE:
740
ADDRESS:5738 N. LOLA AVETELEPHONE:
(559) 907-2596
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 6DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Alex Babakhani TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Inspection - Infection Control. LPA met with and explained the purpose of the visit with Administrator/Facility Designee Alex Babakhani (AD).

LPA toured the facility inside and out. Upon entry, LPA observed visitor log/symptom screening and sanitizer. Covid-19 symptom and precautionary signs are posted at entry and throughout the facility. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed soap, paper towels and hand washing signs in bathrooms. LPA observed required food supply, paper products, 30 days of PPE and resident medications. Cleaning/disinfecting products and sharps/knives were locked. LPA reviewed resident emergency contact information. Fire extinguishers are dated 5/8/22. Fire and Carbon Monoxide alarms were observed in working order. Administrator Certification expiration: 5/17/2024

No deficiencies were cited during this inspection.


An exit interview was conducted. A copy of this report was left with AD whose signature confirms receipt of these documents.

LPA requested the following updated forms by 3/2/2023: Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (LIC 402 if applicable),Designation of Facility Responsibility (LIC 308), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (LIC 402 if applicable), Personnel Report (LIC 500), Emergency Disaster Plan (610E), Client Roster (LIC 9020), Current Liability Coverage (documents reviewed during visit).
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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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