107208891-9-19-2023-24-AS-SMOA-CWRLJ8-20231019084730

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107208891
Report Date: 09/19/2023
Date Signed: 09/19/2023 02:46:45 PM

Unsubstantiated

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
07/14/2023 and conducted by Evaluator Mary Garza

COMPLAINT CONTROL NUMBER: 24-AS-20230714165225

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:	09/19/2023
		UNANNOUNCED	TIME BEGAN:	02:22 PM
MET WITH:	Administrator, Steve Patel		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Licensee did not follow proper eviction procedures for resident

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 visitand 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 visit LPA conducted interivews and reviewed records (resident roster, staff roster with contact information, physicians report, Letter of Agreement, Admission agreement, emergency contacts, copy of eviction provided in the last 6 months, SIRs for month of June and July 2023).Records reviewed and staff interviews indicate R1 was not evicted and left on their own from the facility with outside care provider.

Although this allegation may or may not have occurred, the allegation listed above does not met the preponderance of evidence standard per Title 22. No deficiencies cited. Exit interview completed with Administrator, Steve Patel. A copy of this report given.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: 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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