547201120-1-16-2024-24-AS-SMOA-D23LU6-20240202080321

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 547201120
Report Date: 01/16/2024
Date Signed: 01/16/2024 05:08:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
10/30/2023 and conducted by Evaluator Kamaldeep Kaur

COMPLAINT CONTROL NUMBER: 24-AS-20231030120725

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: 25	DATE:	01/16/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Esmeralda Coronado		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not ensure that resident's call light was operable.
Facility did not place resident's call light within resident's reach.
Facility did not administer medication as instructed by hospice.
Facility did not safeguard resident's medication.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) K. Kaur arrived at the facility for a subsequent visit to deliver findings. LPA met with Administrator Esmeralda Coronado and explained the purpose of the visit and reviewed the elements of the allegations. LPA delivered the following complaint investigation findings.

The Department investigated the allegations listed above. Based on observations the resident’s (R1) call light was operable. Based on observations R1’s bedroom had a call button next to his bed. Based on interviews with staff resident also wore a lanyard with a call button. Facility administrated medication as per doctors orders unless medication was refused by resident.

Based on observation and interview of staff and residents, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore these allegations are unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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

LIC9099 (FAS) - (06/04)

Page: 1 of 1