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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167201075
Report Date: 08/14/2024
Date Signed: 08/15/2024 02:36:10 PM

Document Has Been Signed on 08/15/2024 02:36 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:EVERGREEN HOMEFACILITY NUMBER:
167201075
ADMINISTRATOR/
DIRECTOR:		FRENCH, ZORIAFACILITY TYPE:
735
ADDRESS:11277 EVERGREEN LANETELEPHONE:
(559) 589-0124
CITY:HANFORDSTATE: CAZIP CODE:
93230
CAPACITY: 6CENSUS: 1DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Licensee: Zoria FrenchTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst’s (LPA’s) J. Leffall and K. Kaur conducted an unannounced visit on 8/14/24 for the facility’s annual inspection. LPA’s met with Licensee, Zoria French. There is currently 1 resident who resides at this facility. LPA’s inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. LPA’s observed 2-day perishable and 7-day nonperishable. During kitchen tour, LPA’s observed kitchen window screen torn.
Fire extinguisher was purchased on 8/26/23. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. At 1:54pm LPA’s observed Detergent, Roundup and Disinfecting Spray unlocked in storage area next to staff room. LPA’s observed backyard gate to have a latch on the outside, preventing licensee to open backyard gate during inspection. LPA's observed gate getting stuck on ground, thus not allowing gate to open allowing enough clearance for exit.

LPAs completed a medication audit. Medications were stored in a locked cabinet in the kitchen/ dining area. MARs and medications were reviewed. At 3:54pm LPA’s observed PRN medication not documented with required information. Based on record review LPAs observed 1 out of 1 resident that had 2 medication dosage that were missing. A sample of staff files were reviewed to have CPR/First-Aid, Training, and Health Clearance. Resident file review revealed missing LIC 602 and TB clearance. LPA’s observed Admission Agreement, Personal Rights.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610 the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Exit interview conducted with Licensee and copy of report provided with Appeal Rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 08/15/2024 02:36 PM - It Cannot Be Edited


Created By: Jacques Leffall On 08/14/2024 at 04:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN HOME
FACILITY NUMBER: 167201075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 LPA's observed Detergent, Roundup and Disinfecting Spray not locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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Licensee have staff lock all chemicals in the staff room.
Type A
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 resident's file review revealed no Medical Assessment/LIC 602 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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Licensee to schedule Dr's appointment and submit documentation by due date. Licensee to submit updated Physician's reports when received.
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 Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/15/2024 02:36 PM - It Cannot Be Edited


Created By: Jacques Leffall On 08/14/2024 at 04:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN HOME
FACILITY NUMBER: 167201075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Licensee did not have documentation of TB clearance, the licensee did not comply with the section cited above 1 out of 1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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Licensee to schedule Dr's appointment and submit documentation by due date. Licensee to submit TB clearance when received.
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1, R1's medication had a start date of 8/5/24, filled date 7/24/24, 8 pills should be given. However 10 pills were given which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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Licensee to submit statement of intent to conduct inservice medication training and submit documentation to CCLD when completed.
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 Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/15/2024 02:36 PM - It Cannot Be Edited


Created By: Jacques Leffall On 08/14/2024 at 04:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN HOME
FACILITY NUMBER: 167201075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 1 out 1, kitchen window screen torn which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2024
Plan of Correction
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Licensee will replace or repair window screen and submit receipt/pictures by due date.
Type B
Section Cited
CCR
80075(b)(5)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 1 out 1 PRN medication not documented with required information which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2024
Plan of Correction
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Licensee to obtain/create log containing PRN documentation requirements, and have staff retrained on medication training.
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 Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/15/2024 02:36 PM - It Cannot Be Edited


Created By: Jacques Leffall On 08/14/2024 at 05:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN HOME
FACILITY NUMBER: 167201075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1, backyard gate was observed to have latch on outside, preventing licensee to open backyard gate during inspection which poses an immediate health, safety or personal rights risk to persons in care. LPA's observed gate getting stuck on ground, thus not allowing gate to open allowing enough clearance for resident to exit.
POC Due Date: 08/15/2024
Plan of Correction
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Licensee to submit statement of intent to repair or replace latch and gate door. Licensee to submit receipt/pictures to CCLD when completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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 Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5