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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208891
Report Date: 02/28/2023
Date Signed: 03/14/2023 08:45:36 AM


Document Has Been Signed on 03/14/2023 08:45 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
SIERRA CASCADE AC/SC, 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: 6DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Administrator, Andrea HansenTIME COMPLETED:
04:08 PM
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On 2/28/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced infection control/annual visit. LPA met with Administrator, Andrea Hansen, explained reason for visit was COVID pre-screened and was permitted entry into facility. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms at time of visit.

Required postings including coughing/sneezing etiquette and hand washing posting observed at hand washing stations and throughout the facility. Furniture in common areas are spaced to promote physical distancing. A 2-day supply of perishable and 7-day supply of non-perishable food was observed. Bedrooms have required furnishings and lighting. Facility telephone was working A supply of PPE is located in hallway storage room. The 30 day supply of medication is located in a locked kitchen cabinet.



Linens, hygiene and cleaning supplies observed..First Aid kit has all required items. Fire Extinguisher last serviced 3/9/22. LPA requested the following updated forms by 3/2/2023: LIC 308, LIC 309, LIC 500, LIC 610D, and LIC 9020.

No deficiencies cited during todays visit. Exit interview completed with Administrator, Andrea Hansen. A copy of this report was given.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023
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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