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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201120
Report Date: 01/11/2024
Date Signed: 01/11/2024 04:55:54 PM

Document Has Been Signed on 01/11/2024 04:55 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 RESIDENCEFACILITY NUMBER:
547201120
ADMINISTRATOR:CORONADO, ESMERALDAFACILITY TYPE:
740
ADDRESS:3030 W. CALDWELL AVETELEPHONE:
(559) 732-3265
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 40CENSUS: 25DATE:
01/11/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Esmeralda Coronado TIME COMPLETED:
05:15 PM
NARRATIVE
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On 1/11/2024, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct a Continuation 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.
At 10:45 AM LPA observed during first annual visit laundry room door was propped open by a hanger and disinfectants, bleach and laundry soap was accessible to residents. Based on staff interview laundry room door was propped open because the door gets jammed/stuck. LPA observed facility common areas which were furnished with sufficient seating.

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 16, 2023. Bathrooms were properly equipped with non-slip mats and grab bars.

Residents observed with several care givers in commons areas playing music and exercising. 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.

Carbon monoxide detector tested and operational in hallways. Memory care dining area toured. At 11:33 AM Memory care shower observed with broken/chipped tile and black like substance in the areas. Several rooms toured. At 12:10 PM LPA tested hot water temperature between 104 and degrees F and 131 degrees in several resident bathrooms. The tour continued to the facility dining room and facility kitchen. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed sufficient non-perishable and perishable foods. At 1:29 PM LPA observed the Ice Machine to have brown buildup underneath the door lift area.

Continued to next page...
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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 01/11/2024 04:55 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 01/11/2024 at 03:22 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 RESIDENCE
FACILITY NUMBER: 547201120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 2. Based on interview with staff; Laundry room door was proped open due to it getting jammed. Tile in the memory shower was chipped which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Based on interview laundry room door has been repaired. Licnesee to repair/replace broken tile and submit pictures and invoice once repair. Licensee to schedule repair and submit documentation to CCLD by date.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 3 out of 3 bedroom water temperature tested. Two rooms in memeory care water tested at 126.2 and 132.5. One room tested in AL side 104.8 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee to adjust water heater temperatures between 105 to 120. LPA will retest water heater temperatures at a later date.
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: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/11/2024 04:55 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 01/11/2024 at 03:22 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 RESIDENCE
FACILITY NUMBER: 547201120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

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 2 out of 2 water tested at 126.2 and 132.5 and did not have warning signs which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee to test all room water temperatures and place warning signs on Taps delivering water at 125 degree F (52 degrees C) or above
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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 disinfectants, bleach and laundry soap was accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Laundry door has been repair. POC during inspection.
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: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/11/2024 04:55 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 01/11/2024 at 03:22 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 RESIDENCE
FACILITY NUMBER: 547201120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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; Expired food observed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licnesee to go through all food and remove expired food and ensure food is checked periodically to remove expired items
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
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1; Ice Machine observed to have brown buildup underneath the door lift area.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licnesee to ensure deep cleaning of ice machine and submit pictures to CCLD by due date
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: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
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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: 01/11/2024
NARRATIVE
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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.

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

LPA is requesting the following documents be submitted to the Fresno CCL office by 1/18/2024: 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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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