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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208891
Report Date: 08/16/2023
Date Signed: 08/16/2023 03:53:13 PM


Document Has Been Signed on 08/16/2023 03:53 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 COURTFACILITY NUMBER:
107208891
ADMINISTRATOR:HANSEN, ANDREAFACILITY TYPE:
740
ADDRESS:1415 W SCOTT AVETELEPHONE:
(559) 222-4876
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 5DATE:
08/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:31 PM
MET WITH:Administrator, Steve PatelTIME COMPLETED:
04:32 PM
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On 8/16/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility for an unannounced case management visit. LPA met with Direct Care Staff, Lisa Gomez. Administrator, Steve Patel was contacted and arrived a short time later. LPA introduced self, explained the reason for visit 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.

This case management visit is being completed to return daily logbooks that were provided to the Fresno Regional Office.

No deficiencies cited during todays visit.

Exit interview completed with Administrator, Steve Patel.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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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