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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167201075
Report Date: 07/19/2022
Date Signed: 07/19/2022 01:31:37 PM

Document Has Been Signed on 07/19/2022 01:31 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:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Licensee Zoria FrenchTIME COMPLETED:
01:30 PM
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On 07/19/2021, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was allowed entry by Licensee Zoria French.

Visitor log-in, masks, and disinfection station was observed upon entry. LPA did not observe temperature screening at entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. 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: gloves, and masks and hand sanitizer. Facility needs gowns and N95 masks. Fire extinguisher in kitchen last serviced on 3/14/2022 and was fully charged. 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 issued during this inspection.

LPA is requesting the following documents be submitted to the Fresno CCL office by 7/26/2022: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Licensee. Report signed on-site by Licensee and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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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