547201120-10-4-2022-24-AS-MYAG-CJVNRC-20221004104115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547201120
Report Date: 10/04/2022
Date Signed: 10/04/2022 10:41:23 AM

Document Has Been Signed on 10/04/2022 10:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 27	DATE:	10/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Martha Brewer, Assistant Administrator		TIME COMPLETED:	10:50 AM

NARRATIVE

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On 10/04/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with Martha Brewer, Assistant Administrator (AA) upon entry. AA stated Administrator not available to attend meeting. LPA conduct tour with AA. All residents were present during the inspection.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Bathroom designated for hand washing by front entrance. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings were not observed.

Food supply was checked and appeared to be an adequate supply. LPA checked residents’ locked medications. LPA observed 30 days PPE supplies. LPA and AA observed six fire extinguisher served date ranges from 11/03/2021 through 08/27/2020. Resident’s room toured and observed to be adequately furnished and lit. LPA observed shared residents’ bed to be at least 6 feet apart. All bathrooms are observed with securely fastened grab bars. LPA observed bathrooms trash bin with no lid. Hand washing posting observed by bathroom sinks. Outside tour and observed clear and free of debris. Staff records were reviewed for good health and infection control training. Half of the resident records were reviewed and have updated emergency contact information.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 10/10/22. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 9282, Administrator Certificate, and current liability insurance. A copy of this report and appeal rights was provided to the Assistant Administrator.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022

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 10/04/2022 10:41 AM - 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN RESIDENCE	FACILITY NUMBER: 547201120
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(d)(2)

Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA and Administrator Assistant observed five out of six Fire Extinguisher serviced date expired: Fire Extinguisher 1 has a service date of 8/02/2021, Fire Extinguisher 3 serviced date of 08/02/2021, Fire Extinguisher 4 serviced date 08/02/2021, Fire Extinguisher 6 serviced date of 08/27/2020, Fire Extinguisher 7 serviced date of 08/02/2021 which poses an immediate health and safety risk to the residents.
	POC Due Date: 10/05/2022
	Plan of Correction
1 2 3 4	Licensee shall submit proof of fire extinguisher replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 10/05/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022

LIC809 (FAS) - (06/04)

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