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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201120
Report Date: 10/07/2021
Date Signed: 10/07/2021 03:18:56 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:
10/07/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Esmeralda Coronado, AdministratorTIME COMPLETED:
10:15 AM
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On 10/07/21 Licensing Program Analyst (LPA) M. Yang arrived unannounced at the above facility to conduct a Plan of Correction (POC) visit from deficiency cited on 09/21/21. LPA met with Administrator Esmeralda Coronado.

LPA toured facility with Administrator. LPA observed signal systems in each room for each resident to utilizes.

No deficiencies issued during this visit.

Exit interview was conducted. Administrator was informed that as a COVID-19 precautionary measure, this report 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: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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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