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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547201120
Report Date: 05/02/2022
Date Signed: 05/02/2022 09:33:15 AM

Unsubstantiated


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
02/15/2022 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220215131602
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: 31DATE:
05/02/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Assistant Administrator Martha BrewerTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident assaulted another resident while in care as the result of lack of care and supervision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/02/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to deliver finding on the above allegation. LPA introduced self, stated the purpose of the visit, and met with Assistant Administrator Martha Brewer.

During the course of the investigation, LPA reviewed record and conducted interviews with staffs. Staffs observed incident and attended to resident immediately.

Based on LPA record review and interviews which were conducted, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
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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