<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209371
Report Date: 01/27/2025
Date Signed: 01/27/2025 11:48:49 AM

Document Has Been Signed on 01/27/2025 11:48 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
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: 6DATE:
01/27/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:32 AM
MET WITH:Administrator, Minakshi RoychoudhuryTIME VISIT/
INSPECTION COMPLETED:
11:48 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 1/27/25 an Informal Meeting was conducted at the Regional Office. Present were:

CCL Staff: Licensing Program Manager (LPM), See Moua, LPM, Alexandria Walton, Licensing Program Analyst (LPA), Mary Garza, Licensee, Rajat Roychoudhury, Administrator, Minakshi Roychoudhury and Designee, Shailesh "Steve" Patel.

The purpose of the office meeting is to discuss concerns regarding the Facilities. Facility was licensed 10/18/23. The Department has completed the annual inspection on 10/22/24. Facility was offered and declined Technical Support (TSP) on 10/30/24. A case management visit was completed on 01/08/25. Deficiencies were issued during both of visits.

During the meeting discussions of concerns and operations of the facility. Meeting covered the deficiencies cited.

1) Personal Accommodations and Services: storage area accessible through bedroom
2) Oxygen Administration -Gas and Liquid: signs posting and reporting to Fire Department
3) Resident Records: pre-admission, reappraisals, medical assessments, TB, etc.
4) Personal Accommodations and Services: Open patio area without railing/lighting

The following were also discussed and explained:
- Compliance does not mean just completing POCs after the Department issue citations. The facility should aim and be proactive in making sure its operation meets Title 22 regulations. The Department is transparent that the regulations and CARE Tools are available.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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 3
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: 01/27/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
CONT...

- The Licensee has declined TSP services. TSP is not mandatory. By declining, the licensee communicates that it can be compliant. Although the LPA has a consultative role, the Administrator by maintaining an active certificate, understands all the laws, regulations, and Title 22 to operate.
- Clearing Proof of Corrections – Clearing the POC is the responsibility of the LPA. The LPA was there during the inspection. The facility should communicate with the LPA when there are questions regarding the POC.
- Administrative Actions - Continued non-compliance means the Department may take Administrative Action. This includes any of the following: revocation of the licensee, exclusion of staff, Administrator certificate de-cert, etc. The inimical conduct of any staff, administrator and licensee, including false statements to the LPA or Department, falsifying records and jeopardizing the health and safety of the residents, may result in Administrative Actions.
- ALW Program and Hospice – residents being in the ALW Program, on Hospice, or Home Health does not negate the facility and its staff of the responsibility for providing care and supervision.

Licensee was informed that deficiencies can affect the facility/residents and their license. Enforcement laws and regulation for licensed facilities were covered.

The following POCs were not cleared and a new date of 2/7/25 was provided to submit the POC:
1) Open patio is without hand railing/lighting.

The following deficiency was cited during today’s office meeting: Resident Records

Exit interview completed with Licensee, Rajat and Administrator, Minakshi. A copy of this report, deficiency and appeal rights given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/27/2025 11:48 AM - It Cannot Be Edited


Created By: Mary Garza On 01/27/2025 at 11:42 AM
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: 01/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2025
Section Cited
CCR
87506(a)

1
2
3
4
5
6
7
87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
1
2
3
4
5
6
7
Administrator stated they will provide a plan of correction in writting. Records will be reviewed for completetion and accuracy. Written plan will be sent to CCL by POC date.
8
9
10
11
12
13
14
This requirement was not met as evidence by: LPA observation of resident files. During the annual records were observed incomplete. Physicians report was incomplete/inaccurate. Pre-admission/reappraisals missing. Physicians’ orders missing for hospital beds/bed railing.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
Page: 3 of 3