107208891-7-15-2021-24-AS-SPIY-C4YNN2-20210716103602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107208891
Report Date: 07/08/2021
Date Signed: 07/15/2021 10:38:27 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2021 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20210512141824

FACILITY NAME:	EVERGREEN COURT		FACILITY NUMBER:	107208891
ADMINISTRATOR:	HANSEN, ANDREA		FACILITY TYPE:	740
ADDRESS:	1415 W SCOTT AVE		TELEPHONE:	(559) 222-4876
CITY:	FRESNO	STATE: CA	ZIP CODE:	93711
CAPACITY:	6	CENSUS: 6	DATE:	07/08/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Lisa Luna - Caregiver/Manager		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff conduct poses a risk to residents

INVESTIGATION FINDINGS:

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On this date, Licensing Program Analyst (LPA) David Ayers arrived unannounced to conduct a follow-up complaint inspection. LPA identified himself and discussed the purpose of the visit with Administrator Andrea Hansen. Administrator agreed that Staff Lisa Luna would represent the administrator during the visit.

During the course of the investigation, the Department toured the facility, conducted staff and resident interviews, and reviewed records. On May 11, 2021, there was an incident between staff members at the facility. Residents stated they did not witness the incident. Residents and staff members stated that there were no issues with staff members at the facility. Residents stated that they feel they are well cared for and looked after. The Administrator conducted training and adjusted the staff schedule to ensure residents needs would be well met.

The allegation is Unsubstantiated. No deficiencies were cited during the inspection. Exit intwerview conducted. A copy of the report was proivded to the administrator via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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