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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 02:21:16 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
09/14/2023 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20230914143545
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:
12:30 PM
MET WITH:Administrator, Steve PatelTIME COMPLETED:
02:21 PM
ALLEGATION(S):
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Staff did not ensure the sliding door was fixed in a timely manor
Staff did not ensure all door alarms are working properly
INVESTIGATION FINDINGS:
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On 9/19/2023 Licensing Program Analyst (LPA) M. Garza arrived at faiclity to complete an unannounced initial 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 visit LPA conducted interivews, made observations and reviewed records (daily logs). Daily log book notes that the sliding door in the washroom was not working properly. LPA observation during visit showed the auditory alarms at the facility not functioning. The allegations listed above have met the preponderance of evidence standard per Title 22 and are SUBSTANITATED. Deficiencies cited on LIC 9099D.

Exit interview completed with Administrator, Steve. A copy of this report and appeal rights 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)
Page: 1 of 2
Control Number 24-AS-20230914143545
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 B
09/29/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Administrator to discuss with Licensee to see if door needs replacement or maintence call. Maintenence to be completed and verification in the form of receipt or video will be provided to CCL by POC date.
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This requirement was not met as evidence by: LPA observations of sliding doors not properly opening and closing. Observation of daily log notes this issue. This poses a potential health, safety and/or personal rights risk to residents in care.
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Type B
09/29/2023
Section Cited
CCR
87705(j)
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87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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Per Administrator auditory alarms will be replaced and a copy of receipt or video will be provided to CCL by POC date.
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This requirement was not met as evidence by: LPA interviews with staff and observation of auditory alarms present not functioning .This poses a potential 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)
Page: 2 of 2