547201120-1-19-2022-24-AS-MHON-CBBPN3-20220204102713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547201120
Report Date: 01/19/2022
Date Signed: 01/19/2022 12:45:19 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
11/18/2021 and conducted by Evaluator Mai Yang

COMPLAINT CONTROL NUMBER: 24-AS-20211118090221

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: 32	DATE:	01/19/2022
		UNANNOUNCED	TIME BEGAN:	11:24 AM
MET WITH:	Esmeralda Coronado, Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Neglect/lack of care and supervision resulted in the resident sustaining a pressure injury.
Neglect/lack of care and supervision resulted in the resident being hospitalized for malnutrition.

INVESTIGATION FINDINGS:

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On 01/19/2022, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with Administrator. LPA met with Administrator, Esmeralda Coronado.

The Department investigated the above allegations and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove they did or did not occur therefore the allegations are UNSUBSTANTIATED.

No deficiencies issued.

An exit interview was conducted. As a COVID-19 precautionary measure, a copy of this signed report will be provided via email and an electronic read receipt confirms receiving this document.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

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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