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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167201075
Report Date: 09/08/2022
Date Signed: 09/08/2022 02:21:52 PM

Document Has Been Signed on 09/08/2022 02:21 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: 2DATE:
09/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Licensee/Administrator Zoria FrenchTIME COMPLETED:
02:30 PM
NARRATIVE
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On 09/8/2022, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct a Case Management visit. LPA introduced self, stated the purpose of the visit, and met with the Licensee/Administrator Zoria French.

The purpose of this visit is to follow up on an Incident Report that was submitted to the Fresno CCL office on 9/1/2022 regarding missed medications and medications errors.

LPA reviewed medications, MARs, and Centrally Stored Medications Logs. Based on R1 medication review medication was potentially missed or disturbed incorrectly and/ or log not marked correctly.

Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6.

An exit interview conducted with Licensee/ Administrator. Report signed on-site and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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Document Has Been Signed on 09/08/2022 02:21 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 09/08/2022 at 01:47 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: 09/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2022
Section Cited
CCR
80075(b)(5)(C)

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80075(b)(5)(C) Health Related Services. A record of each dose

is maintained in the client's record.

This requirement was not met as evidence by:
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POC Cleared during visit. Administrator will conduct employee training and will place a check and balance for medication distribution.
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Based on records reviewed, staff failed to
complete the MARs for one resident in care,
which poses an immediate Health and Safety
risk to the residents.
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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 Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022


LIC809 (FAS) - (06/04)
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