547201120-10-15-2021-24-AS-MHON-C932BS-20211123161536

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547201120
Report Date: 10/15/2021
Date Signed: 10/15/2021 12:28:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2021 and conducted by Evaluator Melinda Medina

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210421125758

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: 34	DATE:	10/15/2021
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Melanie Tantingco Esmeralda Coronado		TIME COMPLETED:	12:26 PM

ALLEGATION(S):

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Resident pushed another resident causing injury
Residents are not being changed timely

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) M. Medina conducted a subsequent visit to facility to investigate complaint. LPA identified herself and discussed the purpose of visit with Licensee, Melanie Tantingco. Also present during complaint visit was Administrator, Esmeralda Coronado.

LPA conducted interviews, and reviewed documentation received during complaint investigation. There was an incident reported involving R1 stating R1 tripped due to shoes they were wearing, causing injury to chin. This information is also noted in facilities computer based logging system. There is no reference to an incident between R1 and R2 as reported to Department by complainant. Per Administrator, residents who are incontinent are checked every two hours and changed as needed but there is no documentation charted in resident files. LPA was unable to interview residents due to physician diagnosis and inability to answer questions.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. No deficiencies cited.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Melinda Medina	TELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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