<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201120
Report Date: 09/21/2021
Date Signed: 09/21/2021 01:19:41 PM

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 RESIDENCEFACILITY NUMBER:
547201120
ADMINISTRATOR:CORONADO, ESMERALDAFACILITY TYPE:
740
ADDRESS:3030 W. CALDWELL AVETELEPHONE:
(559) 732-3265
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:40CENSUS: 34DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Esmeralda Coronado, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/21/2021, Licensing Program Analysts (LPA) M. Yang and S. Doucette arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPAs introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with Administrator Esmeralda Coronado. LPAs conducted a tour with Administrator. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms are observed with trash cans with no lid. LPAs observed no hand washing posting by bathroom sinks. LPAs checked residents’ locked medications and observed a 30-day PPE supplies. Food supply was checked and there appeared to be an adequate supply. Fire extinguisher observed to be last serviced 08/02/2021. Staff records were reviewed for infection control training. Facility staff was observed with mask on. All residents have updated emergency contact information. Staff records were reviewed for infection control training.

LIcensee will submit the following requested forms/information to Fresno CCL by: 09/27/21. Due to COVID-19 precautionary measures: LIC 308 Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan for Residential Care Facilities for The Elderly, LIC 9020 Register of Facility Clients/Residents, updated Liability Insurance, LIC 309 Administrative Organization, LIC 808, and current Administrator certificate and health screening.

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

Exit interview was conducted. A plan of correction was developed and reviewed with the administrator. Administrator was informed that as a COVID-19 precautionary measure, this report and appeal rights will be provided via email and an electronic read receipt confirms receiving this document. Report signed on-site.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: EVERGREEN RESIDENCE
FACILITY NUMBER: 547201120
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(i)(1)(A)
(i) Facilities shall have signal systems which shall meet the following criteria:

(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:

(A) Operate from each resident's living unit.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not have a signal system available for each resident in each room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2021
Plan of Correction
1
2
3
4
The licensee agrees to put a signal systems in each room for each residents to utilizes by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2