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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167201075
Report Date: 09/22/2021
Date Signed: 09/22/2021 02:23:44 PM

Document Has Been Signed on 09/22/2021 02:23 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:EVERGREEN HOMEFACILITY NUMBER:
167201075
ADMINISTRATOR:FRENCH, ZORIAFACILITY TYPE:
735
ADDRESS:11277 EVERGREEN LANETELEPHONE:
(559) 589-0124
CITY:HANFORDSTATE: CAZIP CODE:
93230
CAPACITY: 6CENSUS: 3DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator Zoria FrenchTIME COMPLETED:
10:30 AM
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Licensing Program Analyst LPA's Shawna Doucette and Mai Yang conducted an Annual Inspection on this date. LPA's were met by Staff Carlos French and discussed the purpose of the visit. LPA and Administrator Zoria French began the tour at the front entrance/office of the facility. Administrator Zoria French responded to the facility to assist with the inspection.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed behind a locked laundry room door. LPA observed the following personal protective equipment in a storage cabinet in laundry room; face shield, gloves, and masks and hand sanitizer. Facility needs gowns and N95 masks. Staff records were reviewed for infection control training. LPA observed all facility staff wearing masks. Resident’s files have updated emergency contact information.

No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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