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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208891
Report Date: 03/16/2022
Date Signed: 03/17/2022 10:30:03 AM


Document Has Been Signed on 03/17/2022 10:30 AM - 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:EVERGREEN COURTFACILITY NUMBER:
107208891
ADMINISTRATOR:HANSEN, ANDREAFACILITY TYPE:
740
ADDRESS:1415 W SCOTT AVETELEPHONE:
(559) 222-4876
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 5DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Andrea HansenTIME COMPLETED:
11:30 AM
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On 3/3/2020, Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct a Required Annual inspection. LPA met with Licensee/Administrator Andrea Hansen. Administrator certificate is current with renewal date 12/2/2022.

LPA toured the facility inside and out. All passageways and exits were clear and free from obstruction. The facility was adequately furnished and at a comfortable temperature. All smoke detectors and the carbon monoxide detector were operational. The outdoor space had enough seating for residents in a covered area. The fence had a closing gate with a secure latch. LPA observed a two day supply of perishables and a seven day supply of nonperishable food stuffs. LPA toured all resident bedrooms and bathrooms. Bedrooms were adequately furnished and lit. Resident bathrooms had nonskid mats and secure grab bars in showers, and secure grab bars near toilets. Medications were kept in a locked cabinet in the kitchen, and medications appeared to be administered properly. Chemicals and cleaning supplies were kept in a locked cabinet. Facility had sufficient hygiene items and linen supply for residents.

LPA reviewed Infection Control protocols and best practices with Licensee/Administrator and facility Disaster Plan. No deficiencies cited during the inspection. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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