547201120-10-8-2024-24-AS-KKAR-D9UURT-20241008154916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547201120
Report Date: 10/08/2024
Date Signed: 10/08/2024 03:49:53 PM

Document Has Been Signed on 10/08/2024 03:49 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	EVERGREEN RESIDENCE		FACILITY NUMBER:	547201120
ADMINISTRATOR:	CORONADO, ESMERALDA		FACILITY TYPE:	740
ADDRESS:	3030 W. CALDWELL AVE		TELEPHONE:	(559) 732-3265
CITY:	VISALIA	STATE: CA	ZIP CODE:	93277
CAPACITY:	40	CENSUS: 30	DATE:	10/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Administrator Esmeralda Coronado		TIME COMPLETED:	04:15 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 10/08/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct a Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff. LPA met with Administrator Esmeralda Coronado LPA conducted facility tour with Administrator. All pathways, entrances and exits were clear from obstruction. LPA observed facility common areas which were furnished with sufficient seating. The tour continued to the facility dining room and facility kitchen. At 11:14 AM LPA observed unlocked medication pills without a label, Eye drops and Hydrogen Peroxide in a cabinet in the dining area. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed 7-day nonperishable and 2-day perishable foods. At 11:18 AM LPA observed the Ice Machine to have Black mold underneath the door lift area and observed the inside of the lid was cracked. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. Fire extinguishers observed throughout the facility with service date of October 3, 2024. Bathrooms were properly equipped with non-slip mats and grab bars. Residents observed in dining room playing Bingo. Carbon monoxide detector tested and operational in hallways. Memory care dining area toured. LPA observed delayed egress doors. Facility observed with a signal system. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. It was verified that there are at least two staff on duty who are CPR certified. Staff files were reviewed for good health. It was verified that current staff on duty is CPR certified. At 1:05 PM LPA observed 3 residents with dementia diagnosis had medical assessment that were a year old. Continued to 809-C

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

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 10/08/2024 03:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN RESIDENCE	FACILITY NUMBER: 547201120
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(29)

General Food Service Requirements

(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one; LPA observed the Ice machine with possible black like mold which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2024
	Plan of Correction
1 2 3 4	Licensee agrees to drain and empty the ice machine and do a deep clean before using and submit pictures of the ice machine of proof of cleaning by due date.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1; LPA observed unlocked medication pills without a label, Eye drops and Hydrogen Peroxide in a cabinet in the dining area which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2024
	Plan of Correction
1 2 3 4	Administrator removed and locked the medications during inspection. Administrator agrees to provide in-service training for medication storage and submit records 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	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/08/2024 03:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN RESIDENCE	FACILITY NUMBER: 547201120
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 residents Medical assessments were over a year old, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2024
	Plan of Correction
1 2 3 4	Administrator agrees to schedule appointments and show documentation of scheduling for new medical assessments. Once new medical assessments are received Administrator will submit copies to CCLD.

Type A

Section Cited

CCR

87465(h)(5)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 residents medication pill count was observed to have 8 pills extra. Staff admitted to transferring medication from old bottle to new bottle, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2024
	Plan of Correction
1 2 3 4	Administrator agrees to submit a statement of intent to provide in-service training for all medication techs regarding medication regulations by due date. Administrator agrees do a spot audit for next month to ensure issues are not recurring.

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	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

Page: 3 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN RESIDENCE	FACILITY NUMBER: 547201120
	VISIT DATE: 10/08/2024

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During Medication Audit LPA observed R’s medication was not logged in Centrally Stored Medication and Destruction Record (CSMDR). During Pill count it was observed pill bottle had extra 8 pills, Staff informed LPA medication was transferred from one bottle to the other so that is why the count is off.

Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/15/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Administrator. Civil Penalty assessed for repeat violation. Report signed on-site; a copy of this report, 809D with appeal rights were provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

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