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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201120
Report Date: 08/26/2023
Date Signed: 08/26/2023 12:36:05 PM


Document Has Been Signed on 08/26/2023 12:36 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: 26DATE:
08/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:43 AM
MET WITH:Administrator Esmeralda Coronado TIME COMPLETED:
01:00 PM
NARRATIVE
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On 8/26/2023, Licensing Program Analyst (LPA) K.Kaur arrived unannounced for complaint inspection and conducted a case management in conjunction. LPA met Administrator Esmeralda Coronado and introduced self and explained the reason for the visit.

LPA conducted a tour of the facility with Administrator. LPA observed unlocked Bleach and Laundry detergent in the laundry room in Building A (Assisted Living). LPA observed in Building B (Memory Care) unlocked chemicals and cleaning supplies in the dinning room cabinet.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

An exit interview was conducted with Administrator including discussing the plan of corrections. Report signed on-site. Printed copy provided with 809D page and appeal rights.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2023
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 2


Document Has Been Signed on 08/26/2023 12:36 PM - 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: EVERGREEN RESIDENCE
FACILITY NUMBER: 547201120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2023
Section Cited
CCR
87309(a)

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87309 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:
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Administrator had staff lock laundry room door. Chemicals in Memory care storage were removed and placed in locked area. Administrator to complete an in-service training with all staff in regards to locking disinfectants, cleaning solutions and submit to CCLD by due date.
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LPA observed Bleach and Laundry detergent in the laundry room and unlocked chemicals and cleaning supplies in the dinning room cabinet.
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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 MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2