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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209371
Report Date: 05/31/2025
Date Signed: 05/31/2025 05:13:18 PM

Document Has Been Signed on 05/31/2025 05:13 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: 6DATE:
05/31/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:56 PM
MET WITH:Administrator, Steve PatelTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On 5/31/2025 Licensing Program Analyst (LPA), M. Garza completed an unannounced case management visit. LPA met with Care Giver, Noelia Luna, explained reason for visit and was permitted entry into the facility. Administrator, Steve Patel was contacted and arrived some time later. LPA completed a health and safety check on residents in care. 6 residents observed in dining room having breakfast. A tour of the facility was completed inside and out.

This case management visit is being conducted due to LPA's observation of:
  • R1's records. LPA reviewed facility unusual incident reports provided by the facility. No reporting has been submitted from 2/14/24 through 5/15/25, with the exception of R3's death on 9/25/24. LPA observed a hospice care plan provided by Administrator, Steve dated 09/05/2024-12/03/2024. The plan provided was observed to be outdated and reveals a head wound treatment. LPA has requested a copy of R1's current hospice care plan and incident report for the injury that hospice was treating.
  • LPA observation of the Guardian Roster at 9:15 am on 5/31/25. Staff 1 was not associated to the facility. If not corrected this poses an immediate risk to the health safety and or personal rights of residents in care. ***An immediate civil penalty in the amount of $500 is hereby assessed.***
  • LPA observed R2's physicians report dated 2/24/25 stating Insulin Lispro 7 units TID with meals. LPA observed medication in a lock box located in the refrigerator. Interview with R1 disclosed R1 is not being provided medication because "their hand is too unsteady and are unable to administer themselves". Interview with Administrator disclosed home health is coming in 1x weekly and providing R1 the injections. LPA requested Centrally Stored Medication Destruction Records (LIC 622) and Home Health Care Plan. Administrator stated Home Health Care Plan is not at the facility.
CONT...
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/31/2025 05:13 PM - It Cannot Be Edited


Created By: Mary Garza On 05/31/2025 at 02:10 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: 05/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2025
Section Cited
CCR
87633(b)

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87633 Hospice Care of Terminally Ill Residents (b) A current and complete hospice care plan shall ...(4) A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility.
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Administrator stated they will contact hospice agency to update hospice to get a current care plan. Administrator stated they will provide a copy to CCL by POC date.
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This requirement was not met as evidence by: LPA observation of R1's hospice care plan provided by Administator, Steve dated 09/05/2024-12/03/2024. This poses an immediate health safety and or personal rights risk to residents in care.
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Type A
06/02/2025
Section Cited
CCR87411(g)(2)

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87411 Personnel Requirements - General
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
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A review of Guardian Roster at 12:16 pm on 5/31/25, verifies Licensee has added S1 to their roster. POC cleared.
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This requirement was not met as eivdence by: LPA observation of the Guardian Roster at 9:15 am on 5/31/25. Staff 1 was not associated to the facility. If not corrected this poses an immediate risk to the health safety and or personal rights of residents in care.
***An immediate civil penalty in the amount of $500 was assessed.***
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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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/31/2025 05:13 PM - It Cannot Be Edited


Created By: Mary Garza On 05/31/2025 at 03:07 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: 05/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2025
Section Cited
CCR
87202(a)

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87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
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Administrator immediately removed locks during LPAs visit. POC cleared.
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This requirement was not met as evidence by: LPA observation of 3 exit doors (exit #1, exit #8 and #7) to have a door lock at the top preventing residents from exiting. If not corrected this poses an immediate health safety and or personal rights risk to residents in care.
***An immediate civil penalty in the amount of $500 is hereby assessed for fire clearance***
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Type A
06/02/2025
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Administrator will provide a POC in writting. Administrator stated all incidences will be reported to all required parties. In-service training will be completed on reporting requirements. In service sign in sheet and training material will be provided to CCL by POC date.
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This requirement was not met as evidence by: LPA observation of R1s hospice plan indicating R1 was being treated for a head wound. Review of facility incident reportings does not show facility reported to CCL. If not corrected this poses an immediate health safety and or personal rights risk to residents in care.
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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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Mary Garza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 05/31/2025
NARRATIVE
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CONT...
  • During tour of facility LPA observed large white locks secured to the door blocking fire exit door from being opened. Locks were located at the top of 3 sliding doors to outside, inaccessible to residents reach and preventing exit (photos taken). 1 located in hallway near R1's bedroom, 1 located in the family room and 1 located in living room. LPA observed facility sketch and fire clearance to read exit #1, exit #8 and exit #7. All hidden by the curtains. ***An immediate civil penalty of $500 is hereby assessed***

  • LPA has requested a copy of R1 and R2's Admission Agreements and R3's death report dated 9/26/24, admission agreement and hospice care plan to be provided to CCL no later than 6/2/2025.

Deficiencies cited per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809D. If not corrected, the violation with have a direct and immediate risk to the health safety and or personal rights of persons in care. ***Civil penalties are being assessed in the amount of $500 for criminal record transfer and fire clearance.***

Exit interview was conducted with Administrator, Steve Patel. A copy of this report, deficiencies, civil penalties and appeal rights were discussed and provided to Administrator. A plan of correction was developed by Administrator and reviewed by LPA.
NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Mary Garza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2025
LIC809 (FAS) - (06/04)
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