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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209371
Report Date: 10/22/2024
Date Signed: 10/22/2024 05:35:13 PM

Document Has Been Signed on 10/22/2024 05:35 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 COURTFACILITY NUMBER:
107209371
ADMINISTRATOR/
DIRECTOR:		ROYCHOUDHURY,MINAKSHIFACILITY TYPE:
740
ADDRESS:1415 WEST SCOTT AVENUETELEPHONE:
(559) 222-4876
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 5DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:09 AM
MET WITH:Administrator, Minakshi RoychoudhuryTIME VISIT/
INSPECTION COMPLETED:
05:44 PM
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On 10/22/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Direct Care Staff, Noelia Luna, introduced self, explained reason for visit and was permitted entry into the facility. Administrator, Minakshi Roychoudhury was contacted and arrived a short time later.

LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. Residents observed in common areas and in rooms. There is currently 2 residents on hospice at the time of the inspection. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 09/18/2024. Last fire drill on 07/17/2024. Water temperature measured 116.4 degrees F in restroom #2. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets in hallway. Sharps and medications were located in locked cabinets. LPA observed sufficient seating under covered patio areas.

The following issues were observed during todays visit: Chemicals observed in 3 of 3 restrooms unlocked and accessible, vents in hallways in need of dusting/air filters, restroom #2 tub in need of cleaning, food in freezer not dated/stored properly, chemicals/items posing a harm in office unlocked and accessible, walls and doors in need of wiping down, chemical observed in resident #6 bedroom, storage area accessible through resident #6 bedroom, chemicals/items posing a harm next to storage shed and outside back door accessible and unlocked, open patio on back of facility observed without railing and lighting posing a hazard, left side gate not self-latching.
CONT...
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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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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 COURT
FACILITY NUMBER: 107209371
VISIT DATE: 10/22/2024
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CONT...

LPA requested the following documents to be submitted to CCL by 10/29/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Deficiencies cited per Title 22 on attached 809D. TV's and TA's provided. Exit interview completed with Administrator, Minakshi. A copy of this report, deficiencies, TV's, TA's and appeal rights provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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Document Has Been Signed on 10/22/2024 05:35 PM - It Cannot Be Edited


Created By: Mary Garza On 10/22/2024 at 05:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EVERGREEN COURT
FACILITY NUMBER: 107209371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observations of vents in hallways in need of dusting/air filters, restroom #2 tub in need of cleaning, food in freezer not dated/stored properly, walls and doors in need of wiping down, storage area accessible through resident #6 bedroom. This poses a potential health safety and or personal rights risk to residents in care.
POC Due Date: 11/01/2024
Plan of Correction
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Administrator stated all staff training will be completed. Training material and in-service sign in sheet will be completed and submitted to CCL by POC date. Pictures will be taken of correction made and submitted to CCL.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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