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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208891
Report Date: 09/19/2023
Date Signed: 09/19/2023 02:59:30 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
07/13/2023 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20230713080935
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: DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Administrator, Steve PatelTIME COMPLETED:
03:59 PM
ALLEGATION(S):
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Staff not providing residents medications as prescribed.
INVESTIGATION FINDINGS:
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On 9/19/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced complaint visit. LPA met with Direct Care Staff, Victoria Pugh, explained reason for visit and was permitted entry into the facility. Administrator, Steve Patel was contacted and arrived a short time later. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms.

During investigation LPA conducted intereviws and reviewed records. Interview with staff showed staff are not providing medication within the required time frames. Records reviewed show the MARS and the Central Stored Medication Logs indicate that residents are not being provided medication as prescribed. The allegation listed above meets the preponderance of evidence standard per Title 22. Deficiencies cited on LIC 9099D.

Exit interview completed with Administrator, Steve Patel. A copy of this report and appeal rights have been given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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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Control Number 24-AS-20230713080935
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN COURT
FACILITY NUMBER: 107208891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2023
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.
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Administrator will provide a plan of correction in writting to CCL by POC date. Training to be provided to all staff. Training material and in-service sign in sheets to be provided to CCL for verification.
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This requirement was not met as evidence by: LPA observation of MARS and Centally Stored Medication Log not being completed properly. LPA interviews with staff indicate this was not being completed properly. This poses an immediate health, safety and/or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
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